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QUELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> N.4e, 304 E. Weber,Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 DrF <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED — <br /> kpplication 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 /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of Sari Joaquin County Public Health Services,Environmental Health Division. <br /> Assessor's <br /> NELL Location�I .S�cuaJ� Cross Street C1ty ��A Zip 1 s Parcel# <br /> PROPERTY Owner �� �(1l�cvt+T '� Address �' S'�� City No►h�CcC zip 9S331 Phone# Z3 18�I1a0 <br /> —tZegc`I <br /> C57 Contractor <br /> a ��t�\. - Address P� aM- LAN CityES\&'*~ Zip°ISLy1 Uc# Phone# 91k�1-14 100 <br /> C.% <br /> 1l0 �'tL. �o Uc# Phone# CJ ZZ <br /> Consul tf motor ��`��"Y`CaQ .i.r�IfAddress• 1 Clty IY"w <br /> GIS Coordinates:X ,Y ,Township' Range Section <br /> WORK TO BE PERFORMED: DESTRUCTION(choose type below) <br /> D NEW WELL/BORING{CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER`) D OVERBORE <br /> [)SOIL BORING# D PRESSURE GROUT <br /> SWELL# r*� S a 7r1W <br /> "Other. <br /> Grout Specifications: <br /> COMMENTS: <br /> TYPE.OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING 0 HOLLOW STEM DIA,OF BOREHOLE MULTIPLE CASINGS?]]YES ONO WELL CASING DIA: <br /> D EXTRACTION [I AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: D STEEL D PVC. []OTHER: <br /> VAPOR MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED:. D AUGERS D HOSE <br /> AIR SPARGE a PUSH POINT GROUT SEAL PUMPED: ayes D No (NOTE: MAXIMUM FREE-FALL DEPTH 1S 30') <br /> D SOIL BORING D HAND AUGER GROUT SPECIFICATIONS: BOLTED TRAFFIC BOX or, 0 STOVE PIPE <br /> 0 OTHER; D OTHER APPROX.BORING DEPTH . <br /> CONDUCTOR CASING PROPOSED?_L ! (if YES,list specifications here): <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 /> 1 hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, lesl�nd Regulations,and all applicable California State Laws. <br /> Signed x � TttlelCompany t-t 9 y� w <br /> Print Nam.-19, Date— <br /> DEPARTMENT USE ONLY a �� <br /> SITE MAP IN UNIT IV FILE,ADD SS: <br /> WORK PLAN DATED: <br /> Application Accepted Date Issued 0 Area <br /> A <br /> PP ` ' <br /> Grout Inspection By Date Final Inspection By <br /> Destruction Inspection By Date ' <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT]SERVICE REQUEST# INVOICE <br /> C-57 WC -WAIVER_ C-57 Letter of Aut orization to sign per it_Encropchment doc 9/27/00 <br /> E0 3E)V8 N00-1J HlAIA EEbE89060Z 99:ET T00Z/ /Z0 <br />