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04-20-2001 03:40PM TO � 19 <br /> OWI I NA L <br /> VVE<L PERMIT APPLICATION FORM. (� <br /> Lam' (�n,C•� lnl��I � <br /> &D SAN;JO.AQUIN COUNTY PUBLIC HEALTH SERVICES L�T ENVIRONMENTAL HEALTH DIVISION (PHS-EH©) jAn� Q3 <br /> 304 E.Weber, Third Floor, Stockton, GA., 95202 <br /> (2�g) qSg qqg ENVIRQI�HENT HEALTH <br /> PERMIT/SERVICES <br /> MON-REFUNDABLE PERMrr EXPIRES 1 YEAR FROM DATE MSUEO <br /> Appllcetlon Is hereby made to San,laaquiri County fora permit to construct and/or Install the work described. This application Is made in compliance with San <br /> Joaqul County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,EmrironmFinat Health Division. <br /> :oat j Assessor's <br /> effLocation 'P`}�S CtF►c-- 'A46, Cross Streetf1E,1a"- 1W City $7OcY-mrJ zIpT5PQ7 Parc*0 47-�110-3 <br /> 7ipt <br /> S7&j L,aco�-N e�(3i1.L pLv►San <br /> PROPERTY Owner LweALw Pa 6wr-S UrA Address C Ervz'ECL City Tzip O�a7 Phone# YTS-YID <br /> C-57 Contractor I ax Aaaress 4 q stiERis E cttyVati p9 �Lire 6b3�1'I�one�--j?t Tri-3370 <br /> sa3S o•os P6cT A04YL <br /> Cchsultant/Sub Contraclo6s� rm°JS„uc. Address b2. *too City Uc# PhonQW29 �PS-I 800 <br /> GIS Coordinates:X Ay Township Range Section <br /> WORK.TO BE_P_ERFORM913_ <br /> ,NEW W ELL/BORING(CPT.GEOPROBI YDROPUNCH,HAND-AUGER,OTHEK') 0� p DESTRUCTION(Choose type Wow) <br /> G# it OVER-BORE <br /> n W ELL# 13 PRESSURE GROUT <br /> -Other. Grout Specifications; <br /> COMMENTS; <br /> TYPE OF WELL, iSTALLATION TYPE rQNSTRUgTION SP CIFICAT O S <br /> 13 MONITORING 13 HOLLOW STEM DIA.OF BOREHOLE C MULTIPLE CASINGS?E]YES NO WILL CASING t]IA:�f� <br /> 13 EXTRACTION 13 AIR HAMMERIORIVEN CASING THICKNESS_TYPE OF CASING: Il STEEL 0 PVC Q OTHER- <br /> iI VAPOR p MUD ROTARY DF,PTH OF GROUT SEAL.0-310' .__,__ TR£MIE TYPE TO BE USED: U AUGERS it HOSE <br /> 1]AiR SPARGE APUSH POINT GROUT SEAL PUMPED: QYes {]No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> ,;(SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS: N64GEl,46vT' <br /> B OTHER: T n OTHER APPROX.BORING DEPTH 3,p ` 0 BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? Eh {itY_8,list specificatlanshere): <br /> -COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNFr 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 State Laws. <br /> Signed TiVelCompany f�` 7-(5r-r SGrE✓►ITSi T`/jAI+tS rNC. <br /> Print Name ^� Date f rD <br /> /UPARTMMENT USE ONLY y� <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 6-4 � �QN-l.DiP <br /> WORK PLAN DATED: -Z O <br /> Apptiration Accepted By Date Issued <br /> i <br /> rout Ir�pection By bate Final Inspection By to 'O <br /> i Destructlon.Irispectlon By Date <br /> I <br /> COMMENTS t CONOrWNS: <br /> ACCOUNTING ONLY: Ala# <br /> i PE CODES FEE INFO AMOUNT REMITTED CHECK iF REC'D BY DATE PERMIT 1 SERVICE REQUEST 0 INVOICE <br /> SR <br /> 755 <br /> C-57 WC_,_ WAIVER— C•-57 Letter of Authorization to sign permit„_,_,Encroachment doc- 9/27/00 <br /> i <br /> TOTAL P.04 <br />