Laserfiche WebLink
TELL PERMIT APPLICATION FORM <br /> OTIGATION, <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES Fig, <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor Stockton CA. 95202 <br /> (209) 468-3449 <br /> S`�e N o• �$� NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> Assessor's <br /> NELL Location l9 - Cq 5�1� �\V L- Cross Street City C)tocg±± -,Zip Parcel#p� <br /> PROPERTY Owner r ��`o Address x$33ty Zip�52a1 P o <br /> \n` X5-1- QICL- q <br /> Cv7 Contractor V+G,�e r�t`�um' Ze Address ��{ S\� c� city , \�S zipis'b"A Lic# l3 \33 Phone#®�\b- l 3 s S <br /> Consultant/Sub Contractor G 'T 2 Address City rn`J—\ Lic# Phone4 �1 ay`�S 3 Y 6\11V <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: �r �� c.W 0 <br /> 0 NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) DESTRUCTION(choose type below) <br /> []SOIL BORING# OVER-BORE <br /> Q WELL# Q PRESSURE GROUT <br /> 'Other- Grout Specifications: <br /> COMMENTS: W OY.q <br /> W P <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> n MONITORING a HOLLOW STEM DIA,OF BOREHOLE MULTIPLE CASINGS?[]YES 0 NO WELL CASING DIA: <br /> Q EXTRACTION 11 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: I]STEEL []PVC []OTHER: <br /> VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: (]AUGERS 0 HOSE <br /> Q AIR SPARGE []PUSH POINT GROUT SEAL PUMPED: 0 Yes 1]No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> []SOIL BORING HAND AUGER GROUT SPECIFICATIONS: <br /> [] []BOLTED TRAFFIC BOX or []STOVEPIPE <br /> PIPE <br /> OTHER:_0 OTHER APPROX.BORING DEPTH <br /> CONDUCTOR CASING PROPOSED? (If YES,list specifications here): <br /> `COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordina Ru s nd R lations,and all applicable California State Laws. 1 \ D <br /> Signed x Title/Company <br /> Date L) }J J �\ <br /> Print Name `\��rO�r7` �Dlar�lw _ � - � <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: (� <br /> WORK PLAN DATED: - 3 <br /> /. l� Zoo ( Area— <br /> Application <br /> l \ <br /> Application Accepted By i vU� Date Issued l Area <br /> Grout Inspection By <br /> pate inal Inspection By Date <br /> Destruction Inspection By C c. Date /n — <br /> COMMENTS!CONDITIONS: o o Iv 0 2� Sw6.I� e , �j�-4�- <br /> /N6. <br /> 6/J <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# E 'D BY DATE PERMIT!SERVICE REQUEST# INVOICE t( <br /> C-57^ WC_-WAIVER_ C-57 Letter o sign permit_Encroachment doc 9/27/00 <br /> 60 30G6 NOO-13 H13I3 ECO689b60Z 99 :EZ Z00Z/SZ/Z0 <br />