Laserfiche WebLink
w&L PERMIT APPLICATIOIVORM <br /> SITE:, . <br /> MITIGATION <br /> 2003 SAN JOAQUIN COUNTY '€ UNIT IV' <br /> APR 3 0 ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> ENVIpONIO,ENT H, EALTN 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> PERMIT/SER�'ISES (209) 468-3449 <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 9-11153 and the Standards of San Joaquin County Environmental Health Department. <br /> WELL Location �JL [f•-�6�'19/' toss Street �. [L-G�'^ ity Zip r �t1J Parcel# <br /> PROPERTYOwner UYW i -Address= City Zip�hone#—q� 4�a� <br /> t,�, <br /> C-57ContractorWj � � <br /> 7re`s,' �2 =.C426;_ #hone## �/Z06 <br /> Consultant/Sub Cn tr Address = "+I'City + . Lic# Phone#'�*" <br /> GIS Coordinates:X - ,Y Township Range , Section <br /> 10F . . <br /> w <br /> WORK'TO BE PERFORMED: ....5, I <br /> �EW WELL 1 BORING(CPT,GEOPROBE,HYDROPUNCH, ND-AUG �/ OTHER*} w 0 DESTRUCTION (choose type below) <br /> ,H-eOIL BORING#_ _ eyL4/j- /43 <br /> {]OVER-BORE <br /> a WELL# 0 PRESSURE GROUT <br /> *Other; Grout Specifications: <br /> COMMENTS <br /> h <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING a HOLLOW STEM DIA.OF BOREHOLE;Z-11-1'4MULTIPLE CASINGS?p MULTI-LEVEL?0 WELL CASING DIANA- <br /> o EXTRACTION n AIR HAMMER/DRIVEN CASING THICKNESS �.T`YPE OF CASING: 0 STEEL �'0 PVC ©OTHER: <br /> Q VAPOR 1]MUD ROTARY DEPTH OF GROUT SEAL-�fP) r-C/PETREMIE TYPE TO BE USED: eUGERS U HOSE <br /> a AIR SPARGE I Ozone Rf� USH POINT GROUT SEAL PUMPED: a Yes f'No NOT MAXIMUM FREE-FALL DEPTH IS 30'} <br /> X'SOIL BORING a HAND AUGER GROUT SPECIFICATIONS: 067041,�l <br /> (I OTHER: [I OTHER APPROX.BORING DEPTH d BOLTED TRAFFIC BOX or H STOVE PIPE <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 REQUIRtb INSPECTIONS. <br /> I hereby certify that I have prepared this application and that the work will be-done-int accordance vvith.Sii-Joaquin-� j <br /> County Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> I AA <br /> Signed x dN LC�tt�n.L �`_ Title/Company ;_k <br /> Print Name L ~T `C�� Date �'3 a <br /> ,DEPARTMENT USE ONLY <br /> lip <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: At- r--L l o D-37 <br /> Application Accepted Date Issued Area'K7 <br /> /LZI( <br /> Grout Inspection By Date .. l?" Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: (21 <br /> 40-6 ' 6e'V- SL <br /> ACCOUNTING ONLY. AID# j' 1 <br /> PE CODES FEEINFO AMOUNTREMITTED CHECK# REC'DBY DATE PERMIT/SERVICE REQUEST#.:' INVOICE , <br /> SoI $ ^ 139 �b )9311 a 4L s' VO 37 �- <br /> C-57� WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment`doc 8/29/02 <br />