Laserfiche WebLink
ELtw�PERMIT APPLICATION I' RM SITE <br /> ` MTIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-•EHU) o <br /> 304 E. Weber, Third Floor, Stockton, CA,, 95202 <br /> (209) <br /> 468-3449 <br /> 1 <br /> NON-REFUNDABI..E P5=RMrr EXPIRES 1 YEAR FROM DATE ISSUED A 2 z� <br /> Application is hereby made to San Joaquin County far a perrni#to construct and/w install the work described. This appli Is made in©rrtpl with San <br /> in County Development Title.Chapter 9-t 115.3 and the Standards at Sart Joaquin County Public Health Services. -11 :L:11t: Yealltt- 'sian. <br /> .oaGa my �Assessc s LTA{ <br /> S ��l wF?1LacatFa _ �y �►'rte -c_: -CroStreet �a Z!v a59 <br /> Ort • ���� L"'���!/� AddriessT I��o� �Laml__I�tLIL��C�iII�Y��'a'��5 r�T'CF,�C�l��r_ zip 9�d7 7 7 PPhhoonne>�# <br /> PROPERTY Owner <br /> n � � ��,, . Address S0 ,U 1�CLd#—c-s,ron#ra <br /> Carssuftarrtl Sub Cantrador4ar3,jC'Gr C �=7�� Address `� 7 >�3c'�Gu ,City , v�Lice Fhon <br /> GIS coordinates:X ,Y Township Range Section <br /> WCORKTO BE PERFORMED! . <br /> E'N WELL 1 BORING(CPT.GEOPRCEF-HYCROPUNC-4.HAND-AUGER,OTtIER} Q(7ESTRUCTiON(choose type below) <br /> j]SOIL BORING GYEF2-BORE <br /> "ELL# ` 4 Q PRESSURE GROUT <br /> ,other. Grout Specifications- <br /> COMMENTS: <br /> TYPE OF WEi_L INSTALLATION TYPE CON=UCTION SPECIFICATIONS 1} 11 <br /> NiONrrCRING CLI-OW STEM DIA.OF BOREHCLE ,?;S'+ MULTIPLE EASINGS?El YES WELLCASING DIA - <br /> j]EXTRACTION TION 1]AIR I-fAMMERIDRIVEN CASING THICKNESS�� _TYPE OF CASING: []STEEL b?VC ©oTHE^t <br /> Q VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TRS41E TYPE TO BE USED: GE.RS o HOSE <br />' AIR SPARGE {]PUSH POINT GROUT SEAL PUMPED: <br /> - I]Yes No (NOTE: MAXIMUM FRE -FI DEt�'TH IS 30'} <br /> []SOIL BORING 1]HAND AUGER GROUT SPECIFICATIONS: �Q(4- <br /> {]CTHEr"7: OTHER APPROX.ECRING OE?Trl d-O'.f 35 ...._ GLTED TRAFFIC BOX or U STOVE FIFE I <br /> CONDUCTOR CASING PROPOSED?�-(if YES,list speacatiens herey <br /> *COMMENTS. <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules and Regulations,and all applicable California Statee Laws. <br /> Signed x c TitfelCompany. c�` avrxw 5 <br /> Print Name��- +`)} ''+L_` "f''� l� ::LDate E 7 G <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: ,r GrG-t -Gc <br /> WORK PLAN DATED: Area <br /> ;a <br /> Application Accepted By ' Dade Issue a t ---------- <br /> Grout Inspection By Date Date <br /> Final Inspeclon By <br /> Destruction Inspection By Date ! <br /> COMMENTS 1 CONDMONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CO>]ES FEE INFO REMIT-ME)REMITCHECK# REC-D BY DATE PERMrlr/SERVICE RI±QUEST 0 INVOICE <br /> -55 <br /> o 2. z Z�71a <br /> C-57 WC -WAIVED C-57 Letter of Authorization to sign pertnit-L-Y,,-Encroachment doc .9/27!00 <br /> f <br />