Laserfiche WebLink
WEL ERMIT APPLICATION F`�4M <br /> EC��� �, SITE <br /> MA JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> MAY' 2 1 ���� ENVIRONMENTAL HEALTH DIVISION PHS-EHD UNIT 1V <br /> ENVIRONMENT HEA�T 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> PERM;T/SERVICI=S (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 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division" <br /> Assessor's <br /> WE <br /> Location O Cross Street i City Zipq_Q_Y �.Parcel# rl { <br /> PRO <br /> + TY O er Address City Zip f Phone# <br /> C-57 Contracfo��� ,.,_4 Addre ty Zip`?5/*Lic# 252 79Phone0�`f'"'�"�' "? S/ >: <br /> Consultant/Sub Contractor - _ Address .City=��Lic#hone# <br /> GIS Coordinates:X Y Township Range Section 1 <br /> O K TO BE PERFORMED: T _ <br /> EW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION(choose type below) <br /> [�SOIL BORING# [i OVER-BORE <br /> ELL# [I PRESSURE GROUT <br /> *Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICAT ONS i �,�` <br /> a MONITORING �iOLLOW STEM DIA.OF BOREHOLE � MULTIPLE CASINGS?OYES,-60 WELL CASING DIAa <br /> lI EXTRACTION 11'[I IR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL jbj!�C' o OTHER: <br /> VAPOR 11 MUD ROTARY DEPTH OF GROUT SEAL 15riVr TREMIE TYPE TO BE USED: g<UGERS ' []HOSE <br /> IR SPARGE [I PUSH POINT GROUT SEAL PUMPED: 11 Yes [I No OTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br /> a OTHER: p OTHER APPROX.BORING DEPTH V t2a3�F OL-TED TRAFFIC BOX or p STOVEPIPE <br /> / CONDUCTOR CASING PR OSED? (if YES,list specifications here): <br />. . 'COMMENTS: J V�GQL'&=/ 014i1 <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 <br /> County Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> Signed x Title/Company <br /> Print Name Date, <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: Id <br /> WORK PLAN DATED: �^Y-9146a— /Rob <br /> Application Accepted By .l/ Date Issued OLIZe6 Area <br /> Grout Inspection By / SI Date Final inspection By' ZddI Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDrrI1ONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# EC'DY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> C-57 WC -WAIVER C-57 Letter of Auth riza to sign permit Encr6achment doc 9/27/00 <br /> I <br />