Laserfiche WebLink
WELL PERMIT APPL�GATI <br /> O FORM SITE <br /> . � MITIGATION <br /> NVIFtaTINI�t�I A1• SAN ,lOAQUIN COUNTY UNIT IV <br /> ►�t� SEpVICE <br /> PF pMj1 I , TAL HEALTH DEPARTMENT (EHD} k <br /> �, Third Floor; Stockton, CA., 95202 <br /> (209) 458-3449 <br /> NOWREFUNDABLE PERMIT EXPIRES 1 YEAR FR DATE ISSUED,application is made in compliance with San <br /> on is hereby made to San Soaquin County fora permit to construct and/or install the work described. This ap Assessors <br /> S'an Chapter 9 my for <br /> and the Standards of San Joaquin County E ironmental FiealttigDepartment, arcel# is ��1q0 r <br /> County Development -�. City u- 75p 1�� <br /> I v ,� re 5A-, Cross Street er �� c� p g5 Phone# <br /> ocation 5A- Ci <br /> Address �f 97P�yone# 71�� <br /> RTYOwner ...��.-- r �G0" �Ag—ALL # <br /> "VZr4ddress �' � � City <br /> �ntractor �� City •C K31 Phone# 67`� <br /> �, Address Section <br /> Rant I Sub Gntr Range <br /> ,ordinates:X <br /> Y ,Township <br /> TO BE PERFORMED: ©DESTRUCTIOi�I(choose type be!aw) <br /> OVER <br /> N WELL I BORING(CPT,GEOPROBE,HYDROPUNCH,HAND AUGER,OTHER`) 0 PRESSURE GROUT <br /> 11 SOIL BORING# <br /> LL# Grout Specificati ns: <br /> f: <br /> MENTS <br /> !1 <br /> 7SLLATIION TYPE CONSTRUCTION SPECIFICATIONS MULTI LEVEL?0 WELL CASING DIA:_X_ <br /> OF WELLDIA.OF 30REHOLE__ �MULTIPLE CASINGS• [1 OTNER:�., <br /> NITORING LLOW STEM (/ PE OF CASING: 17 STEEL �VC U HOSE <br /> NITORrRACTION I}AIR HAMMER/DRIVEN CASING THICKNESS i � — �UGERS l� S <br /> MUD ROTARY DEPTH OF GROUT SEAL <br /> �� TREMIE TYPE TO BE USED: <br /> ?OR GROUT SEAL PUMPED Yes c (NOTE: M1�►X1MUM FRE -T=ALL DEPTH IS 3t]' <br /> �(l c.VJ <br /> SPARGE 1 Ozone PUSH POINT GROUT SPECIFICATIONS: <br /> :lL BORING a HAND AUGER d BOLTED TRAF C BOX or []STOVE PIPE <br /> [}OTHER APPROX.BORING DEPTH <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> 'HER:�-- - <br /> IAMENTS: <br /> NOTE: OFFSITE BORIN <br /> GS REQUIRE ACCESS OR ENCROACHMENT PER ITS. <br /> CALL THF UNIT IV INSPECTOR 48 WORKING HOURS IN ADV NCE FOR ALL REgUIRED IN with San Joaquin <br /> zreby certify that I have prepared this application and that the work will be done in accordance <br /> unt <br /> Ord, <br /> s, Rule and Regulations, and all applicable California State LaWS <br /> y TitlelCompany O I O /',J �& <br /> ned x Date <br /> f a✓l t GLYI <br /> ntName DEPARTMENT USE NLY <br /> ITE MAP IN UNIT IV FILE, ADDRESS: <br /> IORK PLAN DATED: Area <br /> Date Issued Date <br /> �r-- <br /> pplicatian Accepted By Date O Final Ins ection BY <br /> rout Inspection By Date <br /> )estruction Inspection By <br /> :OMMENTS I CONDITIONS: <br /> u <br /> ACCOUNTING ONLY. AID# PERMIT I SERVICE REQUEST# INVOICE <br /> RECD BY ATE <br /> PE CODES FEE INFO AMOUNT REMITTED CFi�bz� f! �J�QO 3 Z� Z'T <br /> SO g .00T 8/29/42 <br /> C 57 <br /> WC -WAIVER C-57 Letter of Authorization to ign permit Encroachment doc <br />