Laserfiche WebLink
PAYIVitN I <br /> RECEIVI'i7 <br /> WE6-mrPERMIT APrUCATION FOR,''r`r k SITE <br /> 9 z��l� TION <br /> SAN JOAQUIN COUNTY UNIT MITIGAA <br /> c A tv "A' IV <br /> ENVIRONMENTAL HEALTH DEPARTMENT(EHD) <br /> rl iEa` �_,� <br /> r 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209)468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 4pplication 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 /> Jevelopment Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> WELL Location 9_2- S` Cross Street 'Te2-C(4-4' �,G ity Zip Parcel# Assessors <br /> PROPERTY Owner <br /> tt ( O +AAdddrresss��iJ kVC W V � C� ity ,S�Zip9�Phone# OO <br /> C-57 Contractor W 2 Address-� -J FF A�Ci p, �/ %p C� -�j /� l 'n fJ <br /> © ty SLC f+�t7 Zipr✓7T�Li ����f�hone#%�c� �/'3O 7i�-76 <br /> Consultant/Sub Contractor C� Address 83 7 5 u ,' 94- ic# ' Phone# 6 -7 A,564. <br /> GIS Coordinates:X Y Township Range Section <br /> W FfK TO BE PERFORMED: <br /> EW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) a DESTRUCTION(choose type below) <br /> 0 SOIL BORING# a OVER-BORE <br /> 0 WELL# 0 PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS: <br /> fYP F WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS yr J <br /> ONITORING �OLLOW STEM DIA.OF BOREHOLES/W �MULTIPLE CASINGS?Q YES WELL CASING DIA <br /> 216TRACTION o AIR HAMMER/DRIVEN CASING THICKNESS — TYPE OF CASINGXSTEEL PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL /!5 TREMIE TYPE TO BE USED: .ff-rUGERS a HOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes ,&To (NOTE:: MAXIMUM FREE-FALL DEPTH IS 301) <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS:�d <br /> J OTHER: fl OTHER APPROX.BORING DEPTH 30 F1��� �LTED TRAFFIC BOX or 6 STOVE PIPE <br /> CONDUCTOR CASING PRO/POSED? (if YES,list specifications here): <br /> ,( <br /> 'COMMENTS: �'f t)Yl\ �1�-�l�C� �Xe. `y"AL t1�✓1 <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 Reguu/lations,and all applicable California State Laws. <br /> Signed xL1,Gee/ Title/Company v Z"l i �, <br /> ?r nt Name // /)t GvWr �F "71� Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: Z25!m jc c./ -�%79 <br /> WORK PLAN DATED: f�� `�5f 2-,�5'8 j �—� <br /> Application Accepted By Date Issued lArea <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> :OMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE-5/-9/o2_.PERMIT/SERVICE REQUEST# INVOICE <br /> S� / g% o ��� /2- SR# P�5 D Fs-bO <br /> C-57 WC=WAIVER_ C-57 Letter of Authorization to sign permit--kEncroachment doc_ 1/25/02 <br />