Laserfiche WebLink
r iLt bar 1 <br /> d�21�G-� • <br /> APPLICATION LL PERMIT A FORM SITEMITIGATION <br /> SAN JOAQUIN COUNTY UNIT IV <br /> HA 2: 39 <br /> ENVIRONMENTAL HEALTH DEPA 2 <br /> 304 E. Weber, Third Floor, Stockton, C , <br /> Sl�Id �(�PeCil.31i.1 ;;OUNTY <br /> (209) 468-3449 ENVIPOI`!HF-N n <br /> T i•-4 E Pd T <br /> 4� hh r liance with San <br /> NON-REFUNDABLEo�nRNct ani o install the work described.� This is made in comp <br /> for a permit t Environmental Health Department.Assessor's ,� <br /> Application is hereby made to San Joaquin County Parcel# -/ <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of//yySan Joaquipn /County �/��6� zip <br /> -- aa4j <br /> �/ ��/ / W Cross Street / 'e�Ikk�A.r7� City G/t /,/ / <br /> Z��G rj- Iv 41, (5o S-{�l�aN Zip 1SA Phone#�9 7_--- <br /> WELL Location / 3 33 �Clf�c�(/(' City 5 3C <br /> Address <br /> (.0 / ys���� Lic# _Phone# <br /> PROPERTY Owner n0 D� City POV� l�� Zip_ n <br /> i�bz Address / /� L//� / Phone# <br /> C-57 Contractor Sy/ !K City cX 0���"%�Lic#__— <br /> i/(et��etg4�f Address Section <br /> Consultant 1 Sub Contractor �l Range <br /> Y ,Township <br /> GIS Coordinates:X e below) <br /> 0 DESTRUCTION <br /> XNEWRK TO BE PERFORMED: EOPROBE YDROPUNCH,HAND-AUGER,OTHER') PRESSURE GROUT <br /> WELL/BOR�(CPT, ING#OWELL# Grout Specifications: �« t <br /> "Other: <br /> COMMENTS: <br /> INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS � NO WELL CASING DIA: <br /> TYPE OF WELL OF BOREHOLE—MULTIPLE CASINGS. YES PVC 1]OTHER: <br /> �MONITORING []HOLLOW STEM DIA. '----V TYPE OF CASING:: []STEEL [] <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS_ TREMIE TYPE TO BE USED: O AUGERS a HOSE <br /> 0 MUD ROTARY DEPTH OF GROUT SEAL 30 <br /> I]VAPOR GROUT SEAL PUMPED: 0 Yes No (NOTE. ��UM�FREE-FALL DEPTH IS 30') <br /> 0 AIR SPARGE 0 PUSH POINT I <br /> � STOVE PIPE <br /> SOIL BORING <br /> , 0 HAND AUGER GROUT SPECIFICATIONS: p 0 BOLTED TRAFFIC BOX or 0 <br /> 24 f APPROX.BORING DEPTH 3 <br /> 0 OTHER: OTHER CONDUCTOR CASING PROPOSED?___(if YES,list specifications here): <br /> "COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT RED NSPE TIONS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE F accordance with San Joaquin <br /> l be done in <br /> I have rep ed this application andlicablethat hCaliforn e work IIS ate Laws. <br /> I hereby certify an egulations, and all app <br /> County Ordin s, GfaCU� <br /> Title/Company j`U <br /> Signed x Date 0 <br /> Lo <br /> DEPARTMENT USE ONLY <br /> Print Name / <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> 05 <br /> WORK PLAN DATED: �v <br /> Date Issued Z 8-ds Area <br /> Accepted By ate— <br /> Application Date Final Inspection By <br /> Grout Inspection By Date <br /> Destruction Inspection By <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AID# PERMIT I SERVICE REQUEST# INVOICE <br /> PE CODES FEE INFO AMOUNT REMITTED <br /> RECD BY DATE CHECK# L �Z3 SR# D 2n�� <br /> C-57 WC✓ <br /> WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc N 1/2 <br />