Laserfiche WebLink
.an Joaquin .County C"y <br /> z Environmental Health Department SITE <br /> ` 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.co.san-joaquin.ca.us/ehd UNIT IV <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 Environmental Health Department. <br /> Tip�m � /`� �/fi �1(T(Ya"""� Assess _ b <br /> WELL Location oss Street �i Zip Parcel# �j <br /> PROPERTY / i // -t _ <br /> Owner —Cr M;'r L I E�µµw 4h U.�Address �6 � � City ' Zip Phoney#� <br /> C-57 Contractor rI.)L"( Address l q City <br /> Consultant/Sub Cntrl C 11j C'4-'9 �dy, Address 6°�L C.�'l O'k-0 `1 City t1 Lic# Phone# <br /> GIS Coordinates:X t`� Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW Y�JELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') 0 DESTRUCTION (choose type below) <br /> %SOIL BORING# 0 OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE_ 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 HOSE <br /> 0 AIR SPARGE/OZONE <br /> SH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No ( OTE: 1AXIMUM FREE-FALL DEPTA'S 30') <br /> tTHER: <br /> IL BORING AUGER GROUT SPECIFICATIONS <br /> C BOLTED TRAFFIC BOX or STOVE PIPE <br /> p OTHER APPROX.BORING DEPTH D 0 <br /> CONDUCTOR CASING PROPOSED (if YE (] ficati i ,comruent section) <br /> COMMENTS: — <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCRO !T=NT;,f,?ERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> FNS 1RU—NIMf Nl- HEA'TH <br /> I hereby certify that I have prepared this pplication and that the work will be done in accor�TRcq-w�rSanF.loaquin <br /> County Ord' anc Rules and R gul ns, and all applicable California St a e L ws. <br /> ��C tr Title/Company a <br /> Signed x <br /> Print Name <br /> Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# D <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQ E TNVOICE <br /> sR# Dr �3 <br /> C-57 WC -WAIVER_ C-57 Letter of Authorization to sign permit Encronchrr{ t„doc , tS <br /> EHD 29-02-001 <br /> 9/30/2002 <br />