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(MAY. 2: 2005 e 8 29A 2094CP""')R EARTH TECH N0, Q108 P. <br /> FIFTH FLOOR `..� HU <br /> r1_ 02 <br /> FILE COr i <br /> nEy�; <br /> �DYVELL PERMIT APPLICATION FORM SHE <br /> p ? JAN JOAQUIN COUNTY PUBLIC HEALTH SERVICEs MITIGATION <br /> VIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> �NVIP,fl�A>�ENZ� A+T4 E. weber, Third Floor, Stockton, CA., 95202 -� <br /> PE�t�i�I5� V1C�s (209) 468-3449 <br /> ON-REt= NDABL EkNtrr P1kEs I YEAR FROM DATE BSUED <br /> ipplPr n on county Development Ti8 hereby made to Sen Joggyjn County for a permit <br /> aquin <br /> latc Construct and/or install the work deser bmd, This s9ppliradon IS made In compliance with San <br /> itle,Chapter 9-1116,3 and the Standards of San Joaquin County Public Memith Services,Environmental Heallh DivisltltL <br /> WEU Location O!o r ', Cross Street an Lpo City S�OCXtOln 21 Assessor <br /> P95_,�Parcel!/ d7-19D�1 <br /> IROPERTIrownepSt- �ose htS ►111Addrass i oo <br /> �w � � hone3C <br /> 47 CaitVCtarIl If��•9'Q� Add ,V S IN t Cl1y�ZrP —Phos / <br /> /o'Sbg�1(v76� <br /> :on9ultantl Sub Contracsa►Crev �A /� I�. }rJC/ye-J�J��City S';x,,� Licit <br /> ,—.�—� address PhOneif�a9�.Z,3'�-'b� <br /> W Coardinntps:X Y Z�9 C!j <br /> T pip .R�e 66GI <br /> RK TO E PERFO M C'R iJE LOS N/ - <br /> EW WELL 1 SORI ( EOPR06 YOROFUNCH,HAND-AUGER,OTHER') <br /> G d OESTRUCTION(uhaose type below) <br /> )1hWELL 4# a OVER-SORE <br /> ;0M NTS: <br /> Grout SPrrclRralions: iy PRESSURE GROUT <br /> 11P1=OF WELL INSTA CATION TYP C NSYRUCTt N SPECI L1:11CAnoNg <br /> MONITORING p HOLLOW slri f t DIA.OF BOREHOLE _ MULTIPLE CASINGS?U yE5 p NO WELL,CASING DIA: <br /> DCrRACTIoN 0 ALR HAMMERIDRIVEN CASINO THICKNESS TYPE Or CASING-- B STEEL 11 PVC 0 OTHEVAPOR nRS <br /> MUD ROTARY DEPTH OF GROUT SEAL __ �TREMI$TYPE TO BE USED; a AUGr_RS p HOSE <br /> AIR SPARGE 0 PUSH POINT GROUT SEAL_PUMPED: ayes 13 No (NOTI~: MAXIMUM FREE-FALL DEPTH IS 301) <br /> tOlL BORING U HAND AUGER GROUT SPECIFICATIONS <br /> OTH@R—_tT OT HEL R APPROX e0AING DEP <br /> 0 BOLTED TRAFFIC sox or n s'rovs PIPE <br /> CONDUCTOR CASING PROPOSED? (if YE=S,Ilst specifications here), <br /> lal;t)INMEN r15: S f& LL t oi 5 <br /> i.vt,6" P-1� Ys ' c 0 <br /> d2K t <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 W012KWG HOURS IN ADVANCE FOR ALL,REQUIRED INSPECTIONS. <br /> lereby CeMfy that 1 have prepared this application and that the work will be done in accordance with San.Joaquin <br /> Dunty Ordinances s d Regulations,and all applicable California State Laws. <br /> Ined x TIIB/Company <br /> ni NamJ% C' 151 <br /> DEPARTMENT USE ONLY Date �! <br /> TE MAP IN UNIT IV FILE,ADDRESS: b& <br /> OINK PLAN DATED: <br /> picatlon Awepled By Date Issued-- a <br /> aut Lnspeotlon 5y DZLte Final Ins echor <br /> 5tructlon Irispectian By Date <br /> MMENTS/CONDRIONS: <br /> COOUNTING ONLY: AID# <br /> CODES FEE INFO AMOUNT REMITTED CHECK# R€G'D BY DATE PERMIT f SERVICE REQUEST# INVOICE <br /> QO Z-Dgde <br /> 37- -- WC WRECEIVED TIME-50R, 29, ( 9:59AMriZ0ticnfa$ignperMif_y�Encr~oachrne�t'dor.d o/97/W <br />