Laserfiche WebLink
W-'_L PERMIT APPLICATIO'- FORM SITE <br /> r. <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (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 Environmental Health Department. <br /> WELL Location Assessors <br /> S. 1sau ) � Cross Street -<6k SCity S 1 Z{p parcel# rL <br /> 3L <br /> PROPERTY Owner ?e )c 65 <br /> 9( ity_ KZip Phone#JgbA <br /> y[J <br /> C-57Contraclor_yrw Ckn1`Itgq 1�C Address 1416 City�ZipOSL4ULic#-22pJ'444Phone#ri/C,-777-�/0(t <br /> Consultant/Sub Contractor 6rb _Addressj2lu ft2402 Cityl�Lic# Phone# 13CS�i$fid <br /> GIS Coordinates:X 'Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING(CPT.GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) DESTRUCTION(choose type below) <br /> 0 SOIL BORING# ' OVER-BORE <br /> 'Other: `o'1NFI_L# hA,lej L-� aPRESSUREGROUT <br /> �. <br /> COMMENTSGrout Specifications: ' <br /> : _ <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS : $Ge OL++Vc}&& wwe.0 Uxj <br /> � ONITORING 0 HOLLOW STEM DIA. OF BGREHOLE_ ' MULTIPLE CASINGS?D YES ONO W ELL CASING DIA <br /> F0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 75 TREMIE TYPE TO BE USED: D AUGERS (HOSE <br /> D AIR SPARGE D PUSH POINT GROUT SEAL PUMPED:$Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING D HAND AUGER GROUT SPECIFICATIONS: <br /> D OTHER: D OTHER APPROX. BORING DEPTH 75 — D BOLTED TRAFFIC BOX or 0 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 <br /> County Ord'flanc les and Regulations, and all applicable California State Laws. D <br /> Signed x � Title/Company r en t5-F� l 4ay U 4 ?'enn <br /> + <br /> Print Name _ ecto 1;1.� / Date —I I Z Z7/0 Z- <br /> 6 <br /> 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: I AID# FAQa <br /> PE CODES FEE INFO I AMOUNT REMITTED CHECK# REC'D BY DATE —PERMIT/SERVICE REQUEST# INVOICE <br /> 3502 s bol 1&0. 0 <br /> 0 <br /> O 12Iy5 1O01. 2� <br /> C-57_ WC--WAIVER— C-57 Letter of Authorization to sign permit_ Encroachment doc_ 1/25/02 <br />