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77, <br /> DELL PERMIT APPLICATION FORM SITE <br /> ;� <br /> � 1 ' 1 N <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERAO,3rPIP�# N f f <br /> C o C- ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95WSEP 23 P 1.137 <br /> (209) 468-3449 a <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Vplicabon 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 Developmer.i Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> Assessor's <br /> NELL Location- � � �� C.�\ - c Cross Street City <br /> PROPERTY Owner Ctik �mG�Y� � Address �bD �2 City Zip �3 Phone# 7 2 3 O <br /> Iliq \ O&S52 f�,g 5 to 5 p <br /> C-57 Contractor ��\�1� ekddress l `50 � Q ° City��p`_- Lic#-` Phone# a S 3�3�J O <br /> LCQ � �S \\O\ City m�tD Lic# Phone# z o �S <br /> Consultant/Sub Contractor �,sL-7 �� c 9-U Address <br /> GIS Coordinates:X ,Y ,Township Range SOctiOn <br /> WORK TO BE PERFORE DESTRUCTION(choose type below) <br /> NEW WELL/BORIN CP EOPROBE,HYDROPUNC ND-AUGER OTHER`) 0 OVER <br /> �i SOIL BORING# � C —�� <br /> 0 WELL# 0 PRESSURE GROUT <br /> *Other Grout Speclfications: <br /> COMMENTS: Sszx� W P Q \ — 1 03 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING [I HOLLOW STEM DIA,OF BOREHOLE_Z, -MULTIPLE CASINGS?]]YES ONO WELL CASING DIA: <br /> p EXTRACTION U AIR HAMMER/DRIVEN CASING THICKNESS -- TYPE OF CASING: 0 STEEL 0 PVC. p OTHER: <br /> 0 VAPOR Y DEPTH OF GROUT SEAL_f�@ TREMIE TYPE TO BE USED:. 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE PUSH POINT GROUT SEAL PUMPED: 0 Yes D No (NOTE: MAXIM M FREE-FALL DEPTH 1S 30') <br /> I9 SOIL BORIN 0 HAND AUGER GROUT SPECIFICATIONS: �3LP�t- <br /> a OTHER: 0 OTHER APPROX.BORING DEPTH D BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (If YES,list specifications here): <br /> `COMMENTS: �� \ —��^ \-J P <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 Or inan s,Rules and Regulations, and all applicable California State Laws. o 14 <br /> Signed x Title/Company <br /> Print NameDate ZZ Z <br /> DEPARTMENT USE ONLY Q <br /> SITE MAP IN UNIT IV FILE,ADDRESS: N W <br /> WORK PLAN DATED: f— • D <br /> Application Accepted By Date Issued��� rJ Area <br /> Grout Inspection By Date Final Inspection By _Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: l ! / <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# RE 'D BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit_Encroachment doc 9/27/00 <br /> 0 0 <br /> 60 39Gd i 10074 HIAIA ECVS89b60Z 9S:61 100Z/8Z/Z0 <br />