Laserfiche WebLink
cQ `�an Joaquin County <br /> • Enviru amental Health Department S <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br /> L� ` �ff�VITE ION <br /> 'f (209) 468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehdMAR 1 7 2006 UNIT IV <br /> ll Permit Application ENVIRONMENT HEALTH <br /> E COP <br /> YN-REFUNTLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT/SERVICES <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 Environmental Health Department. <br /> Q�� Assessors <br /> WELL Location,;230�-U/�sf `C Cross Street nt VL City T°�� — Zip 9520X—Parcel# 11 <br /> PROP CityZip $Z/o Phone#Zry <br /> 42' <br /> Owner t 5SSAP( (03 <br /> C-57 Contractor(".Q:K- yf`'tf19 Address -V32 &?de City�Q-Zip 2 C Phone#'?I&- L 3S' -111¢p <br /> Consultant/Sub Cntj, vi ed dress u-? _City _Lic#(of5D221 Phone#QUl-q(,07 '1 Da(Q <br /> GIS Coordinates:X Y Township 21J Range to i Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/ BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER,OTHER*) DESTRUCTION (choose type below) <br /> 0 SOIL BORING# OVER-BORE. DIAMETER " <br /> C) <br /> 0 WELL# 'PRESSURE GROUT ✓ �J <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMENTS: 7r),7& 1.UP I a t rOfG.SS Ufa Q fn ri -- <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER: 0 OTHER APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certi that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County or( <br /> i ances, Rules and Regulations, and all applicable California <br /> ��State <br /> �Laws ,�/ _ <br /> Signed x Title/Company V 9104:5 k- 6- <br /> Print Name Yom• � Y,-e ns Date �11-? <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 32-30 tjo r+} West Lune, <br /> WORK PLAN DATED: M o YC 13 200(, <br /> Application Accepted Br+n P.L1 Date Issued Area)4 5 q <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection Byyi`C�d y�`� [ Yn�1p�� , Date 30 -L% <br /> COMMENTS/CONDITIONS: -+ r ' W L' M - <br /> ACCOUNTING ONLY: AID# F <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3503 ' 279 339. 00 SR# d0 � l � 7 <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc <br /> EHD 29-02-001 <br /> 6/22/04 <br />