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03-22-2000 10:22RM FROM - TO 2340538 P.03 <br /> WE PERMIT APPLICATION FM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTALHEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES t YEAR FROM DATE ISSUED <br /> Application Is hereby made to San Joaquin County for a permit to construct andlor install the work described, This appiication is made in compliance wit`. <br /> i San Joaquin County Devdlopment Title, Chapter 9-7715 3 and the Standards of San Joaquin County Public Health Services.Env rormental Health D,v!s:on, <br /> f ya*, a�p-t py-ed 0 J . Assessors <br /> i VL 6�ation fa A 7 7(`4C_ % C o sStreet city. 4VC00&11 Zip"Jsl.d3 -Parcel» / `C6 <br /> PROPERTY OwnerC 07' ^�teGlit ldress City)) Zip�yl d3 hone» <br /> C•57Conbac:d1 V 4 W a1-�r II+"H Address F0 i3ox '116 City_Ts T0;1 DPI OUC=1Z�hone !fi 777'-f✓Z)0 <br /> / 1 EWA <br /> 'j¢E r''5";t�c�,'r 11 <br /> i <br /> Consultant/Sub Contractp <br /> ,L,�Ontil Or EWA T+-t{'Addresse..t[1C 5�+'t�.:I Ciry Slc.'k>4'�LiC- Phone" >G� Xs�-c>��✓Ei ' <br /> GS Coordinates:X .Y ,Township Range Section - ! <br /> I WORK TO BE PERFORMED <br /> I DESTRUCTION(choose t <br /> ANEW WELL I BORING(CPT.GEOPROBE,HYDROP�I NCH,NANO-AUGER.OTHER') _ 0 type below! <br /> ) 7C$OIL BORING a y 'rja [3e3•> OVER-BORE <br /> 0-WELL# s,Nby PRESSURE GROUT <br /> f <br /> -Other; - - <br /> 7 ✓tc l T'N s In (�cvp✓ohm by + H,L� j <br /> COMMENT '.> c> . .11 tie kIL- -f+ll <br /> S'. w Z �rlsls'N yell <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS — <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE -'2 ++ MULTIPLE CASINGS?0 YES 0 NO WELL CASING DIA. <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING. 0 STEEL 0 PVC O OTHER. <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEALv TREMIE TYPE TO BE USED. GAUGERS OHOSE <br /> I� p ATR SPARGE PUSH POINT GROUT SEAL PUMPED )(Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> I SOIL BORING 0 HAND AUGER APPROX. BORING DEP H 3 P D BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> U OTHER 0 OTHER CONDUCTOR CASING PROPOSED? (if YES, list specifications here) <br /> 1 COMMENTS', 1„C✓O,Qc L+iw+P.n f P e V,w.• •I- La }" (.. G + 0 <br /> r- <br /> NOTE: OFFSITF BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Slate Laws.Intl Rules <br /> and Regulations Of the San Joaquin County. Homeowner or.licensed acenl's signature certifies the following'. "1 certify that in the performance of the work <br /> 4 <br /> for which this permit Is Issued;Ishall not employ persons subject to WORKERS'COMPENSATION Laws of California. Contractor's hiring or sub- <br /> contracting signature certifies the following'. "I cantly that in the performance Of the work for which this permit is issued, 'Shall employ persons subject to <br /> e WORKERS'COMPENSATION Laws Of California." <br />( <br /> -AM THE U�"1.1tIT I -(INSPECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS.. <br /> Signeds -1\C�..u..�r' Title/Company /�ICT rtR . i+'Ir coo ln` t�S Coup,,,✓. 4 Jc ;- <br /> I[ :Tfic1,nOICsj QS <br /> Print Name �ON C\ Y2 >�- Date .3 a D _ J <br /> S <br /> SEE_ SIVE MAP IN ;UNIT IV:'WORK.PLAN DATED- pv�:.� <br /> DEPARTMENT USE ONLY f cifC h acyl <br /> Application Accepted By ate Issued O O Are II <br /> Grout Inspection 8y Dale 6 'nal Inspection By e <br /> I Destruction Inspection By Date 3 al Odgn <br /> i <br /> COMMENTS I CONDITIONS: . <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK it REC'D BY DATE PERMIT/SERVICE REQUEST a INVOICE <br /> 3s'ol ( ��.oa a scs� 3 3v ca o0'1Cj a CI <br /> 1/18/2000 <br /> iI <br /> TOTRL P.03 <br /> I <br />