Laserfiche WebLink
VVPL, ERMIT APPLICATION F -RM SIT <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 WAL(209) 468-3449 ul GIU���' <br /> 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 /> WELL Location -7 97S F/fVeH/4 5�4 Cross Street L hr;srxen 96. City Tray Zip 7530 Parcel# <br /> PROPERTY Owner Dr. A.,V Glover Address P 0• RoX 1,055City !r�fy Z;p 95378 Phone# Zoq (o— 0`i9 <br /> r•+St� � N[ct a j9/aH / <br /> C-57 Contractor 6re43 -�a. Address 956 *owe /?aad CityM4rWnt2 Zip 9YSS3 Uc#65667 Phone#0;59.3/3-5860 <br /> Consultant/Sub Contractor 4T"( 4ssoc;-vks X1-c Address( /7tont Alm 4vt CitydfS�V Lic# Phone.#(?O')5 <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> ANEW WELLGRIN CPT EOPROBE,HYDROPU NCH,HAND-AUGER,OTHER') 0 DESTRUCTION(choose type belcW) <br /> SSOIL BORING# / 0 OVER-BORE <br /> 0 WELL# 0 PRESSURE GROUT \ <br /> 'Other: Grout Specifications: I7e47 ' <br /> eeW1en; <br /> COMMENTS. Be►in� fu 00 -t-A- o r vnfi l a t��gni �a�� r14 IaWr tr enIoum lerr Te ?^'' •�✓i�tr: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE I " MULTIPLE CASINGS?0 YES 0 NO WELL CASING DIA:1V4 <br /> EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS N-4 TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: NA m <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> Q AIR SPARGE ,PUSH POINT GROUT SEAL PUMPED: 0 Yes p No (NOTE: MAXIMUM FREE- AL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: ZZ <br /> (I OTHER:_0 OTHER APPROX.BORING DEPTH 2 0 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE V <br /> CONDUCTOR CASING PROPOSED?NA (if YES,list specifications here): <br /> 'COMMENTS: f! <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS 1N ADVANCE FOR ALL REQUIRED INSPECTIONS. �\ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules and Regulations,.and all applicable California State Laws. �1 <br /> Signed x/vc?i� � Title/Company StQ Iq G�a�y� �T� rTSSotigftS <br /> Print NameAJ474°n CbrlS7 Im Date 3 Dy <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 74 75 w- l If' Sffee-f , ln- j <br /> WORK PLAN DATED: 0 <br /> Application Accepted By AL.I nJers on Date Issued O 3 d 9 Area /g•� <br /> Grout Inspection By Date ! 0 PkjeFinal Inspection By Date <br /> Destruction Inspection By Date - <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# PERMIT/SERVICE REQUEST# INVOICE <br /> REC'D BY DATE <br /> 3vo 1 5� 89 887 1 (WR 0soy o W-37139 <br /> C-57_ WC_-WAIVER— C-57 Letter of Authorization to sign permit Encroachment doc 9/27/00 <br /> i <br />