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APPLICATION FOR <br /> 1111ELt PERMIT APP M SITEMITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION {PHS-EHD <br /> 3p4 E.Weber, Third Floor, Stockton, CA-, 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FRO DAT ISSUED Grahon.s mads In cflrnpl�ancewiv�San <br /> on is here1.sy made t4 San,)loaquin[:aunty for a perrrlll to construct and/or Install the work Public <br /> tiedHealth <br /> This aPR <br /> AsSe6sors <br /> �n Caw'+H Development Title,Ctlap1.er 9-11 15.3 and tie tlb0.Standards of Sen Joaciuln County PubUC HeaRh Services.Enwro�menla111eaith Da,ns�an <br /> p Ck ty "O - a Zip q'S o�J Parcell! <br /> JPERTY <br /> t,L acatlon _ LIN c.v11�� Goss srrEet �+✓c �: c� pck}ari ZipJx0�Phone# two IX04-'d• '1- <br /> Owner cdtrt 3S O Poddress hJ.CkaV�e4eV1A ��Ity S�' 057$'-+I�nne# �Io �j4•-1411 <br /> rr r� 11� gj3."J tri d1�A1 1 Cvio V%I 1pAr�4 60 <br />-57 Contractor- rsT Ttn7.1MwT AG6ress [552 PaCtac l Mar?IY�!{tr co3Pl7aT SZ-'�5�2.� <br />; ultantlSub Contractor ICES Address itrrt f Gly��tio# <br /> Phone# 'ala <br /> Y Tpvnlshlp <br /> Range___-----Section <br /> 31S Coordinates X <br /> K TO BE PERFORMI=O• below) <br /> Q DE�UCTiON{choose type <br /> NEW WELL t BORING(GPT.GGOF'ROBE, DROPUNCH HANCf�AUG1=RTIdER ) jj OVER-60RE <br /> .. U SOIL BORING 13 PRESSURE GROUT <br />'�es' IZ WELL# GROUT SPECIFICATION <br /> MMENTS <br /> E OF WELt, iNSTALLATIONI TYPE COt+iSTRUCTION SPECIFICATIONS ]NO WELL CASING DIEL <br /> 1)MONITORING (�HOLLOW STEM DIA.01=SORE>�IOLE-.�,� <br /> MULTI?LE CASINGS?LI YES <br /> CTI �]AIR[•1AMINERlDRIVEN CASING THICKNESS TYPE OF CASING. 4 57EEL J)PVC 1107HEF;L- <br /> n MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED. Q AUGERS QHOSE <br /> FWRGROUT SEAL PUMPED j]Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH 13 30') <br /> Q AIR SPARGE PUSH POINT <br /> OIL 13ORING a HAND AUGER GROUT SpFCIFICATION BOLTED TRAFFIC DOX er p STOVE PIPE <br /> THER bTl•IER APPROX BORING bRPTH <br /> CONDUCTOR CASING PROPOSED)_(If YES-1151.51)COflcations here) <br /> LMENTS <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS O�i pN dROACons In aHMF aN� PERMITS virh an .}oaquin <br /> erelay Certify that I haVe prepared this application and that tht <br /> work Mounty Ordlna:>ces, State La and Rules and Regulations of the$ar>I .1dagUln County. <br /> * CAL.L.THE N INSPE O WORKING HRS IN ADVANCE FOR ALL REQUIRI=D INSPECTIONS <br /> Tille/Campany �C Y tn+; el <br /> Igned x <br /> Date,�p� r <br /> not Name W1. DYl ^� <br /> 0 <br /> SITE MAP IN UNIT IV FILE ADDRESS /WORK PLAN DATED <br /> DEPARTMENT USE_ONLY A<ea <br /> Date issued <br /> pplicabon Accepted9y Finai InspectionBy Dates <br /> Qate <br /> Grout Inspection t3y Date <br /> estruchon Inspec9on gY <br /> OmmaNTS f CONDMONiS' <br /> COUNTING ONLY AID# <br /> PERMIT!SERVICE REQUEST# INVOICE <br /> PE CODES FEE INFO AMOUNT REMRTED CHECK# REC'D BY DAYS <br /> saIN � <br /> C-57 WCIWAIVER C-57 Letter oAuthorization to sign permit Encroachment clot 7/17/00 <br />