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PTFTH FLOCIR <br /> PAGE 02 <br /> � <br /> WEOr4ERMIT APPLI° CAT1C? <br /> N FoRmSITE <br /> SAN JOAQUIN COUNTY-PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PISS--EAD UNIT IV <br /> 304 E. Weber, Third Floor, Stockton; CA., 95202 <br /> P �2 (209) 488-3449 <br /> NON-REFUNWLEPERIJITTEXPIRESI,YEAR� 'I <br /> Rt)n++pAT ISS Ell <br /> aFli tion';S hereby made to San Jcacuin County fcr a,permit to=nstr of andfvr install the wor4c.a nbeC- This e�plicatiort rs made iri con-, �r'ar,ce wr?h wan <br /> :aouip Coup=} Development Title,Chapter 9-1115.3 anQ the 5tardards at San JaaGuir,Oounbf PA Health Services,EnN;ronrnental}learth i?ieigion <br /> ELL l ovation X11 S °�� assessors <br /> Cross F"� A I1Q11��CTty, 7R0 Zip + PartCeS# <br /> RQPEl7TY Owner�T'L!•S o rgddress� V. C Q���(( y <br /> 'j � � <br /> IK1�.�Citf j[�t ZipPhone# �"' <br /> -57 Contraato [1 { Add�ss <br /> ilhone#92S-- -sga a } <br /> crrsu[tant l Sub ContractorwL�p�� �� _ip�rn esa�- E• ld-k 5 � <br /> `�T . . CitYLic;r Phone# Z ; <br /> IS Ccsordinatas:X Y Township Range <br /> 'ORK TO 6E PERFORMED- <br /> NEW <br /> ERF RMED:NEW WELL,SORING(CRF-OPR0F3E HYDRG R N N,A p-AL;(3ER,OTNER`; jj DESTRUCTION;ct;aose type <br /> hEIO:•1) <br /> i` ?SOIL 30R1NG# 0 OVER-BORE <br /> jj W=LL m <br /> )that: fl PRESSURE GROUTJ <br /> .GROU-7 SPECTF[CATiON <br /> MMEH TS. <br /> (PE OF WELL INSIALLaTiON TYPE CONSTRUCTION 9PECIMCATIONS <br /> MCN70RING Q HOLLOW STEM D:A.OF BOREHOi.E �.t1_11_71PLE CASINGS? U YES"t�t40 WEL.LCASING DiA:�� <br /> EXTRAC-.10N a A i R} AN:MSPJ0R;VFNI CASING T HCKNESS �� 7YPE'CF ZyAEWG: C(3��E`L (]PVC �Q7FiER: � <br /> !AFOR [] UD ROTARY- DEPTH OF GROUT SEAL T RENt1F_TYPE=OBE USED: I]AUGERSO c i <br /> AIR SPPAiSE USH POINT GROUT SEAL PUMPED: " es Q No (NOTE: MAXIMUM FREE-FALL DEP•S'4 i"1S 301) <br /> 501L.EORiNG a 1-!ANC A GROUT S?ECfFiCAMON ':fi -,!raii- _�� <br /> OT HER: [].^Tr'Eft� APPROX-BORING OEFTH 1 Q SOL T EC TRAFFIC BOAC or '.STOVE FiPE <br /> CONDUCTOR CASHNC PROP(4S=O? V4 if YES. list spee:t7ca cr,s he:8} <br /> E: I <br /> OMiAENTS: s: f <br /> MOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS Ir <br /> hereby certify that i have prepared this application and that the work wi11 be done in accordance with San Joaquin <br /> ounty Ordinances, State Laws, and Rules and Regulations of the;San Joaiquin County. <br /> I; <br /> 'CALL THE UN[T IV IRSP1 C7 a WORKING HRS IN ADVANCE'FOR ALL REQUIRED INSPECTIONS <br /> c <br /> ;red x Till/Company <br /> ;rt Nagle <br /> SITE MAP IN UNIT IV FILE ADDRESS [WORK PLAN DATED Sge, 0._c-6A C.Add c u.rv.. I, <br /> �-- DEPARTMENT sJSE ONLY -- <br /> )piir+atorn Accepted By Date Issued Area <br /> rc4t Inspection By Date Fina[fnsaectfan ey Date 1 <br /> ?stmcaion Inspection By F ate <br /> OMMrz.14TS f ON IONS: 41 <br /> ` u j <br /> 1 <br /> ACCOUNTINGS ONLY: Al 00 <br /> EI II <br /> 'F CDO€3 FEE INFO AMOUNT RE1411 CKI R C BY bAT i; PERMIT/SERVICE REG�UEST Ir INVOICE <br /> C-57— WC/WAIVE;12 C-57 Letter cf Authoriz i 0 g1, Enicroachment doc 7/1.7YOO <br />