Laserfiche WebLink
WE'L'_t PERMIT APPLICATION FOFtt' SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY UNIT IV <br /> 1I'�WAONMENTAL HEALTH DEPARTMENT(EHD) <br /> 30 E.Weber, Third Floor, Stockton, CA., 95202 <br /> �: r 2 <br /> Q2 t!A R 18 Ppb (209)468-3449 FILL bUr I <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 Joaquin County <br /> Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department <br /> nn!! / �S s=or's <br /> WELL Location 94 06 Mole S+'I`t['+ Cross Stree IX- v{_City 140V Zip Parcel# s' S <br /> n-,, Q � Phone# y 6 -01 <br /> PROPERTY OwnerF rQrC I [ UYIth�A�+dtdress kih �h{_City�G_LZip 7 <br /> C-57 Contractor lT� Address N 7 G GJ City. )+Zi$_Licf Phone# -/006 <br /> Consultant/Sub Contractor /T"Q?� Address.pCamQ ity ic#jCjD�APhone# Y 6 10 7 <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUN H,HAND-AUGER,OTHER-) DESTRUCTION(choose type below) <br /> 0 SOIL BORING# OVER-BORE <br /> p WELL# PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS /� / <br /> a MONITORING Q HOLLOW STEM DIA.OF BOREHOLE j" MULTIPLE CASINGS?a YES ONO WELL CASING DIA:/4 <br /> a EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS_ TYPE OF CASING: p STEEL a PVC a OTHER: L <br /> 0 VAPOR Q UD ROTARY DEPTH OF GROUT SEAL E(rf rrt TREMIE TYPE TO BE USED: O AUGERS a HOSE <br /> ZSOILSPARGE USH POINT GROUT SEAL PUMPED: a Yes o (NOT MAXIMUM FREE-FALL DEPTH IS 30') <br /> BORING a HAND AUGER GROUT SPECIFICATIONS: <br /> Q OTHER: n OTHER APPROX BORING DEPTH 30,C-4 Ge a-BOLTED TRAFFIC BOX or a 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 REQUIRED INSPECTIONS. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, <br /> Rules and Reg tions,andall-a p1" able California State Laws. 1r- <br /> Signed x Title/Company O +- rr " <br /> Print Name a M 1 AIC4&n Date ✓ v <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 116 > LGt...I (V <br /> WORK PLAN DATED: ar �Od Z <br /> Application Accepted By Date Issued Area <br /> Grout Inspection B 0& Date Final Inspection By t <br /> Destruction Inspection By Date n <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3' 18-o2-1 SR# 00 Z'I L 3 <br /> C-57 WC=WAIVER_ C-57 Letter of Authorization to sign permit J&ncroachment doc 1/25/02 <br />