Laserfiche WebLink
r <br /> FILE COPY <br /> ALL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> FEB 2 4 2004 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> i� ►•�, H ALI H <br /> It (209) 468-3449 O N [CF5 <br /> � ES NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is ereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with Sari <br /> Joaquin County Development Title,Chapter 9-111.5..3 and the Standards of San Joaquin County`Environmental Health Department. <br /> d�t/ r �1 /S !/V J U�� �S�S Asrcel# ��7_ ��– � <br /> WELL LoTcation N 11 �l �(/ Cross Street � City Q Zip Parcel# <br /> OwOPER l Dy}jj Mo U� Address PDA� ���/ CityS7�'� "� Zi 95 Phone# I <br /> �7 (a5/O�lv7 ra-3/3-s�� <br /> C-57 Contractor l Address �� �`�1s-�1C&Arn�'"`" iip52Lic# Phone <br /> Consultant/Sub Cntr A G C Address S S? S�Q� CityS Phone#2D I qb? <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> VjA EW WELL/BORING (CPT, ROBE,HYDROPUNCH,HAND-AUGER,OTHER') 0 DESTRUCTION (choose type below) <br /> SOIL BORING# C 0 OVER-BORE. DIAMETER <br /> 0 WELL# PRESSURE GROUT <br /> O'Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS /v/14 TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY EPTH OF GROUTSEAL. � S REMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE GUSH POINT(GP or CPT) ROUT SEAL PUMPED: R-Yes 0 No (NOT:MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS /?iYZ+ ✓1 <br /> 0 OTHER 0 OTHER APPROX.BORING DEPTH �f�5. FC64 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: ` — �� <br /> NOTE: OFFSITE BORINGS RE IRE 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 /> Ccunty Ordinances, Rules and Regulations, and all applicable California State Laws. /- <br /> Signed x f/LJ C. Title/Company L>LV / 14 4-76f L,( <br /> Print Name �) l �(lin L 7 � Date <br /> DE,,P/ARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: � �" ')4 <br /> WORK PLAN DATED: 7`f NQ J 200 <br /> Area ,.1ed �/c0 <br /> Application Accepted By <br /> Date Issu <br /> Grout Inspection By Date Final Inspection By ate <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 29 SR# D© 3766�1 <br /> 16 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc N 9/30/02 <br />