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PAGE 02 <br /> 08/03/2000 11:1e 2094683433 FIFTH FLOOR <br /> IV <br /> YWELL kRMIT APPLICATION FORM SITE <br /> �* <br /> MITIGATION <br /> + SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PSIS-EHD UNIT Ill <br /> 344 E. Weber, Third Floor, Stockton, CA., 95202 j <br /> (249) 468-3449 <br /> IKON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM QATE ISSU ED <br /> =!;cation is hereby made to San Joaquin County for a permit to construct andlar inataii the work descritjeC. This ap9II=tion is made fr%cema Into*ai San <br /> ;aauin County Development Tltie,Chapter 9-11115.3 and the Standards of San Jaaqulrs County Public Health Services,Environmental Health Oivision. <br /> Assessor's <br /> 'ELL Lacation Bross Street Q.rf�4(1P c1P[� Fry S Eby_ 2i: tt'Sac Parcel# FO�:ro��ur�d5 <br /> 'Y-NAddress P t7. tgcs-x g co� Ci ' '+ol zi Sbl� ,ana _�OS�1 M-3 <br /> ROPERTY Owner re tY o <br /> •57 Contracto UJ `lL`n Aaarsss VJ u-C I �p _ cityl1-amt _Zip R57�r Lias 20 hone; I fes,7 �7 SSI 0 d <br /> l cc �1 Se tv�ce s .Lri� She je- - <br /> onsultant l Sub Contracto'U�rkA -� C_r\ViYDnuy ge2L Addrsss (;, <br /> tS Caardinat�s:X„- Y Tawnship Range Section <br /> 'ORI[T P RF RM <br /> NE' ELL BORING(CRT.GEOPRCBE.NYDROPUNCH,HAND-AUGER,OTHER-) a DESTfRUCTtON(choose type belaw) <br /> ALE L) <br /> kq G SAIL BORING# [I OVER-SORE <br /> Q WELL PRESSURE GROUT <br /> )then' GROUTSPECIPiCATION <br /> 3MMENTS. <br /> 41PE OF WE L INSIALLATION TYPE CONSTRICTION$P.ECIFICATIONS <br /> MCNITORING HOLLOW STEM DIA,OF SCREHOLE MULTIPLE CASINGS?11 YES O WELL CASING DLA-.,? <br /> EXTRACTIONAIR HAMMeRlDRiVEN CASING THICKIESSSca- TYPE OF CA<fNG: E1S-EE_ <br /> VVC dOriE~: <br /> VAPOR Ia MUD ROTARY b8PTA OF GROUT SEAL TREMIE TYPE TD BE USE-0; UGERS I]iiOSE <br /> Ail;'.SPARGE [l PUSH PotNT GROUT SEAL PUMP:,.: (j Yes (j NO (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL SORING a HAND AUGER GROUT SP501P4ATION <br /> OTHER- Q OTHER APPQOX_BORING DEPTH S b WOL T EC 7 RAI=FiC sox or Q STOVEPIPE <br /> CONDUCTCR CASING PROPOS='n" &J'6 (4 YES,fist speeiticattcrns here): <br /> . 1, <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> hereby certify that i have prepared this application and that the worts will be done in accordance with San Joaquin. <br /> ourlty Ordinances, State Laws, and Rules and Regulations of the San Jouquin County. <br /> CALL THE UNIT IV INSPECTOR WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS <br /> ar+ed x � :(� �._- TitEelComparFy d` U C <br /> int Name—JN&Aa" Oate <br /> SITE MAP IN UNIT IV FILE ADDRESS MORK PLAN DATED <br /> D PAR T USE ONLY r <br /> ;plication Accepted IS Date issued Area <br /> rut Inspection By Date Finaf fnspection B trate <br /> �strurtion Inspection By 42 Gate <br /> OMMENTS l CONarrlc,Ns: <br /> ij <br /> ACCOUNTING ONLY: AID# <br /> '1#COD@3 FEE INFO AMOUNT REMITTED CHECK ix R5r.;p lVr,71 DATE PERMIT F SERVICE REQUEST 0 INVOICE' <br /> 3.00 l ?q ,06 t Z- d I 1 °I <br /> C-57 WC/WAIVER C-57 Letter of Authoriz art o er'm t Encroachment doc 7!17/04 <br /> i <br /> ri - <br />