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b3E Illi!2093 o8:81 2094683433 FIFTH FLOOR PAGE 02 <br /> WELt"PERMIT APPLICATION FORM SITE <br />' SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-END) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (208) 468-3449 <br /> fil <br /> Appllaation is hereb © -RE B E PEt7mrr R ES YEAR RO b TB SSUED <br /> y J7 to San 4oaquin Ceunty For a permit to construct andlar Install the work described This appiicaimn is made in complrarrce with ear <br />' JoagWn COunty i]evelnpment Title,Chapter 9-1115 3 and the Standards of San Joaquin co <br /> linty Public Health Services,environmental Health Division <br /> WELL.1-kooatro W Crots street Ir11UGpL ST Cay 6 Zip q ?�6 Auessar's <br /> r ► _- I5 Parcel <br /> PROPERTY Owner _yrr .tiG' � Address ft-6�- <br />' G-ST Coritractot 5[ - dL Address <br /> e_ _L CrS+ tilt P- _udk� Phone# 63�$'�f! <br /> Consultant 1 Sub Contractor E Z &t!G 1wCly <br />' cls coordinates-� .Y Tow"" RAn9e Section_ <br /> O O BE 4RKFORMED- <br /> )"EW WILL,!BORING(CPT,GEOPROSR,HYDROPUNCH,HAND-AUGER.amm-) <br /> i7 SOIL BORING# 0 DESTRUCTION(choose type below) <br /> , E"LL# W. U OVER-BORE. <br /> C*jUtMME �IN <br /> 'Ct Grout Specification 1)PRESSURE GROUT <br /> NTS <br />' SOF- Lam- aMLATIO PE Cq STRU ON3PSCIFik3 ON-9 <br /> A:fAONITORING ,11%V' 01-LOW STEM DW.OF BOfREHOLE—e—MUL'T'IPLE CASINGS?n YES <br /> E?CiRAC770N DAIR IiAMMEWDRNEN CASING THICKNESS O WIwLLCAStNt3 DIA ?-'v <br /> VAPOR 0 MUD ROTARY _VO TYPE OF oA we. a STEEL �'VC u OTHER• <br /> AIR SPARGE DEPTH OF GROUT SEAL_*- // <br /> I]PUSH PC31MT' -TR.EMIE TYPE;TO BL USED qQ(UG1=k5 Q HOSE <br /> ly SOIL BORING GROUT SEAL PUMPED Q Yes Q No [NOTE: MAXIMUM FREE-FALL. DE:i�'TM ISS E <br /> Q HAND AUGER GROUT SPECIFICATIONS. f.Ems!$ F: <br /> Il OTHeR 0 OTHER APPROX BORING DEPTH_ 2v/ LTED TRAFFIO BOX Or <br /> 11 STOVE PIPE <br /> *COMMENTSCONDUCTOR CASTING PRCPOSE /iV D7 /1 (if YES,flat wedficatiorm here} <br /> j NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS, <br /> 11 hereby Certify that 1 have prepared this application and that the work Will be dobe in accordance With San Joaquin <br /> Count]►Ordjnah , R es and Regulations,and all appljaatble California State I-aws. <br /> Signe , 1 <br /> Title/Company (0it.S Cr- _ <br /> Print Name -----� <br /> CL Q Oate 14 —03 <br /> D P RIME US O Y <br />'SITE MAP IN UNIT IV FILE,ADDRESS: 15C <br /> WORK PLAN DATED: Zaa <br /> pfloation Accepted By Gate Issued O <br /> rout tnepertion By Area <br /> Date Finel Inspection By pate <br /> DfttrucfEDn Inspeotlan B date <br /> cl), <br /> coNDMONS- <br /> G ONLY- AID# <br /> i�i? F8eINFq AMOiINTREMIITrEp CMECtCAIRECD BY DATE PERMIT!BLIZvICe REQUEST# INVOICE <br /> A 3 a 33 � 5'r <br />�' WC----WAIVER C-57 Letter of Authorizntion to sign permit Encroachment doc <br /> 9/27/07 <br />