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2094EE33433 <br /> - - FIFTH FLOOR !'AGE @� <br /> Past-it*Fax Note 7671 0210 a or a <br /> ca Io or P�9e <br /> To ) _ From <br /> Co rphpt wt tett L <br /> Co <br /> Ctt 4 PhanO# %2 <br /> hone# <br /> ax* 3,'5'-,6,6 Fax )LIcATlanl FORMUNIT ISI <br /> Fax# <br /> BLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION ("PHS-EHD") <br /> 304 E Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3450 <br /> NON-REFUNOASLE PERMIT EXPIRES I YEAR FROM DATE fSSUE.0 <br /> App),carkon Ls hereby made fn San Joaquin County for a perm,t to construct and/or install the work described This application is msde m C¢mP1I&nGe with <br /> San Joaquin County fDevelbpment Title Chapter 9-11 IS 3 and Ine StandartUs of San Joaquun County PUNIC Health Servtc$S,Enirrrgnrrl@nt2I Health Orvrsion, <br /> +�� �I`nGdf CL1G j0 y Clic 9S Assessofs <br /> WELL Location bk Lt ST. Cross Street W _ rcllLp Parcera/�5-03-aa5 <br /> PROPERTY Owner r��s `�7t <br /> C-57 Contractor, Qt}Q �1_)��I111� - ,Address0 ffotvC�d arty f11'1eZ 7sv_ Y3s}}_Lactr3/G5" Pfior,exgaS'+��3' TV at) <br /> v j r 7 _ - <br /> Consultant/Sub Contractor_C44,1>r P q ic n V Address r1� G+ty -°Ll rc# Tiir�'nona fi '9- y8�° <br /> GiS Coordinates X Y Townshlp� R �Range Semon <br /> WORK TO BE PERFORMED <br /> 0 NEW WELL f BORING(CPT- GEOPROeC IdWOROPUNCH HAND-AUGER. OTHER") )(DESTRUCT(ON(Choose type below) <br /> U SOIL BORING it f6 )(OVER-BORE <br /> Q WELL A a PRESSURE GROUT <br /> 1Othor <br /> C,-SvIMENTS. <br /> = OF WE CDNSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br /> it <br /> —�)N?TORIIit0 HOLE-OW STEM WA.OF BOREHOLE 18" MULTIPLE CAS)NGS7 0 YES Q NO WELL CASING,OIA <br /> J EXTRACTION (j A(R RAMMEIJORIVEN CASING THICKNESS GA IIA TYPE OF CASING a STEEL irFvc a OTHER <br /> 0 VAPOR MUD ROTARY DEPTH OF GROUT SEAL_TREMCE TYPE TO 8E US€O Il AUGERS QHOSE <br /> a,RIR SPARGE o PUSH POINT GROUT"SEAL PUMPED (I Yes a No (NOTE- MAXIMUM FREE-FALL DEATH IS 3(31) <br /> D SOIL BORING Q HAND AUGER APPROX BORING DEPTH -'T'f a BOLTED TRAFFIC BOX or *TOVE PIPE <br /> OTHER CONDUCTOR CASING PROPOSE[)?_ _ _(rt YES, Im speclficataorss here} <br /> COMMENTS: <br /> NOTE. OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS! <br /> I ntreby caruty that t have prevared that appibman and Nat the work will be done In acoardance w it,Sart 303gurn COunty Ordmanms State Laws and Rules <br /> ana Regulations of the San J47quMn County Htlmeowiniv or trc&mcd agent's signature certifies The following -1 csrufy Marra rho performanes of the work <br /> for which this permit is issated I sha11 not employ persons subject to WORKMAN'S COMPENSATION laws of Cvhforn+a-" Contracices hmng or sub- <br /> contracnng signature c e,rms the totlawot; 1 certify that u7 the padbirmance of the wcvk top wh,c11 this permit is msual 1 shalt rarrmpfoy persons sub)ect!b <br /> VQCPKMAN S COMPENSATION taws Of Ce%lomia- <br /> E Ap NT MUST CALL d$HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS <br /> OF <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED <br /> OE,PAR'T'MeNT USE ONLY <br /> Appllcmion Accepted By_ 44 A C0,6 -Dare Issued! �0� Q /� Area <br /> Grout Inspection By Dare Final 1n&peCUon By Gale. <br /> 0e,3UuCtf0n <br /> te - <br /> OesVuctfon tnsoecaon By Date <br /> -WMENTS I CONDITIONS <br /> ACCOUNTING ONLY AIDS FACS <br /> PS Co ES FEE INFO I AMOUNT REMITTED CHECKC1CASH REcErvEO BY DATE PF-RMtT/SERVtCE REQUEST MUMS 9A INVQK <br /> 3 5b =4 66 00 1 Z <br />