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D CENENELL ARMIT APPLICATION FO* <br /> SITE <br /> 0 T 2 2006 SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> EN (JNMENT HEALTH304 E. Weber, Third Floor, Stockton, CA., 95202 UNIT IV <br /> PERMITISEMACES (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ,pplication is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San <br /> oaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> nn !' / '. R 1 t� Assessors <br /> JELL Location 35 Ib)ti (a4 >�'r"Y '^ Cross Street E�+ U). City �Et I Zip q� T� Parcel# ? -?-1 0 D <br /> ROPERTY /� / /• (� / f,` Qom, { <br /> owner �e�, i 5i?iiVQ 6!a Address 405 9-41yt4,, �--i 'rL (W)UJCi G/ p 32L �"� , o�jy- <br /> A ty `b�/ ) Zi �/1 Phone# <br /> 57 Contractor ]� �i Ii I l/.. Address 2,33-5 F1,[,Ods ! V4, city e;`t l- Zip 5.5* Liar/#,C' " &1 Phone#-7L-7-yt%�f Shy yG) <br /> onsultant/SubCntr�'1� y1V`'J��►YVry Address �1 �uVn�' AJ Play �Lci#�� 1 ^"^� '1561Z -6,74,--6'7;I'- e <br /> ;IS Coordinates:X Y Township Range Section <br /> JORK TO BE PERFORMED: <br /> ,NEW WELL/ BORING CPT,GEOPROSE,HYDROPUNCH, HAND-AUGER,OTHER-) 0 DESTRUCTION (choose type below) <br /> SOIL BORING# CTI 0 OVER-BORE. <br /> ,IAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> Other GROUT <br /> PECIFIC TIONS I I � i7 <br /> .OMMENTS: lC. M SC klr� ;i1L1 ID Lt IL" 1 c <br /> YPE OF WELL IN TALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING HOLLOW STEM DIA. OF BOREHOLE"_ 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS tilt, TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: UAUGERS 0 HOSE <br /> AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Yes V No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> ,SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS ni?4l Clravd <br /> OTHER OTHER APPROX.BORING DEPTH �0% 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED 110 (if YES,list specifications in comment section) <br /> :OM11AENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> hereby certify th t I h ve prepared this application and that the work will be done in accordance with San Joaquin <br /> ;ounty Ordina s, les Rg a and nd all applicable California State Laws <br /> ,igned x Title/Company -pas <br /> /C�Q�'1� <br /> Tint Name Date <br /> DEPARTMENT USE/ ONLY <br /> 3ITE MAP IN UNIT IV FILE,ADDRESS: <br /> NORK PLAN DATED:_ <br /> kpplication Accepted By �J k,-,W1Date Issued l d I10 0 y Area ) 7 <br /> 3rout Inspection Byl Date ) Final Inspection By <br /> Date <br /> )estruction Inspection By Date <br /> :OMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> D I 1 / l' )>p U� 1,f*- /c) l u �'� <br />