Laserfiche WebLink
an Joaquin County <br />Environmental Health Department <br />600 East Main Street, Stockton, CA 95202-3029 <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />• •![Merl <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 />Assessors �G <br />WELL Location eURRRL /t/o'LGd3✓ _Cross Street J ­5f - U City 7R4e% Zip 9 S 377 Parcel# <br />LA'�✓O /G <br />PROPERTY <br />Ly°�&Vt4tZ41A/ G C iCifyO?.gO ne# 0/ <br />_9�SSSS fps/GS <br />C-57 Contractor �X'Tg Ok/CCIWIAddress fs llywe l/D City ip Lic# Phone <br />ri ed/✓�E�✓i s f, e,Yr��bo�h` y' 91.5 <br />Consultant / Sd7t"Mt'.i�Ffi9i✓ Address �rlt� �/ City Lic# Phone 2 <br />GIS Coordinates: X 'Y Township 9 -S-d1--AX Range S Section—Ar- <br />WORK <br />ection /r- <br />WORK TO BE PERFO IIEB. <br />ORI (CP- . GEOPROBE, HYDRO CH HAND -AUGER, OTHER") 0 DESTRUCTION (choose type below) <br />0 SOIL BbWP411 #_0 OVER -BORE. DIAMETER <br />0 WELL # 77 <br />0 PRESSURE GROUT <br />0 *Other n / GROUT SPECIFICATIONS <br />COMMENTS: <br />/ C, / <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING HOLLOW STEM DIA. OF BOREHOLE 0 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 'S /r-7TREMIE TYPE TO BE USED: 0 AUGERS 0 NOS <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />OIL BORING 0 HAND AUGER GROUT SPECIFICATIONS A16W C,(M4EW1' <br />0 OTHER: 0 OTHER APPROX. BORING DEPTH TRAFFIC BOX or 0 STOVE PIPE <br />COMMENTS: <br />e 4,77(GO' 6•/. <br />in comment section <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />48 WORKING HOURS NOTICE REQUIRED FOR 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 Regulatio d all applicable California State Laws. <br />Signed x '/ Title/CompanySE�/ <br />Print Name Date o <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted Beyer _ V' Date Issued ! , Area �ry <br />Grout Inspection BJ, �Ah - Date A��2f/0'% Final Inspection By <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: l /.8/ 7 <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO AMOUNT REMITTED <br />CHECK # REC'D BY <br />DATE <br />PERMIT / SERVICE REQUEST # <br />INVOICE <br />IVY a7/ <br />sR# <br />C-57 WC --WAIVER C-57 Letter of Authorization to sign permit_ Encroachment doc_ <br />EHD 29-02-001 WEB <br />9/11/2007 <br />