Laserfiche WebLink
aRly San Joaquin County <br /> ,o. �o 0 <br /> Environmental Health Dep artment ' r' <br /> r , <br /> 304 East Weber Avenue, 3rd Floor,Stockton, CA 95202 MITIGA <br /> o- (209)468-3449 Fax: (209)468-3433 Web:www.co.san-joaquin.ca.us/ehd JUN orilTM4 <br /> gcikS ` ENVI <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> f ERMiT/SAF%VIr with San <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 <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> G L�A,f I �II�II Assessors <br /> WELL Location $�� L• N(pgtto%a rSf. Cross Street City S7 K'fDrt Zip `�52-02 Parcel# / �'1/D -O'{ <br /> PROPERTY �l//I I // cc1 <br /> Owner CSV Address�7oyG"u f�t 540r2 Cityip90602Phone# 5'In2-`ISI_ /ZO <br /> C-57 Contractor Address City Zip Lilt Phone# <br /> /e$ ra..,k st fie, <br /> Consultant/Sub Cnlr Corjor' Address 5.'iel City,No�Lic# Phone#201-Z54—OS/B <br /> GIS Coordinates:X ,Y ,Township / /Uor 4 Range e,61,5_t Section 2— <br /> WORK TO BE PERFORMED: <br /> 'XNEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCHHAND AUGER OTHER•) ODESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> 0.Other II II 1 I ' GROUT SPECIFICATIONS <br /> COMMENTS: �reoo�evt wcvL fkbLVrb¢ot ivt `11,.2 alFo-c-W✓_0. (Jgr � 4L , r2S <br /> —r C <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> p MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE O MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS NA. TYPE OF CASING: 0 STEEL p PVC 0 OTHER: <br /> p VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL NA TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> p AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> p SOIL BORING XLAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH Z fv S O BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED NA (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 certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinan ule and Regulations, and all applicable California State Laws. <br /> t <br /> Signed Title/Company Colndor ax Ir+ <br /> 2 '7 <br /> Name � L <br /> Print Nam / <br /> DEPARTMENT USE ONLY Date <br /> SITE MAP IN UNIT IV FILE, ADDRESS: IO / , � J�✓�� <br /> WORK PLAN DATED: 0 0 <br /> Application Accepted By <br /> �t9 e4. Date Issued a ',Q Area �Y <br /> Grout Inspection By Date Final Inspection By Date l? 1 <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: L '>,��r'L" <br /> ACCOUNTING ONLY: AID# F <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> oy SR# 38 <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 9/302002 <br />