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;. WEA)PERMIT APPLICATION F RM SITE <br /> UIN COUNTY PUBLIC HEALTH SERVICES UNIT MITIGATION <br /> DAN JOA <br /> Q UN UNIT IV <br /> OCT 2 2001 ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA,, 95202 <br /> ElI VIRO VENT 1-IEAUH (209) 468-3449 <br /> PEHIv1lT11SERVICES <br /> NON-REFUNDABLE PERNIrT EXPIRES i YEAR FROM DATE ISSUED <br /> Application 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 San Joaquin County Public Health Services,Environmental Health Division. <br /> / Assessor's <br /> ti 7� U Cross yyStreet <br /> F _ Zip2i_'Ve Parcel# <br /> P� wner Address Y( «b0 l.� City z3p�hane# <br /> C-57 Contractor Address„ 2, Lw, i2 City_,, Zrpt e 26Uc#j n e# L <br /> Consultant/Sub Contractor Address City Uc# Phone# 1 <br /> GIS Coordinates:X Y Township Range Section <br /> X TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROSE HYDROPUNCH,HAND-AUGER,OTHER-)-cy Q DESTRUCTION(&case type below) <br /> 1]SOIL BORING# OVER-BORE <br /> f1 WELL# [[PRESSURE GROUT <br /> 'Other Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL WSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING 1]HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?I]YESg�O WELL CASING DIA: <br /> []EXTRACTION 1]AIR HAMMERIDRiVEN CASING THICKNESSTYPE;OF CASING: II STEEL I]PVC BOTHER: <br /> 13 VAPOR ©MUD ROTARY DEPTH OF GROUT SEL _ TREMIE TYPE TO BE USED: []AUGERS OSE <br /> AIR SPARGE PUSH POINT GROUT SEAL PUMPED. a Yes )kNo (NO E: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING I]HAND AUGER GROUT SPECIFICATIONS: <br /> a OTHER:_ n OTHER APPROX.BORING DEPTH BOLTED TRAFFIC BOX or STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> 'COMMEwrs <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 1 have prepared this application and that the work will he done in accordance with San Joaquin <br /> County Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> Signed x ! Titlelcompany ? <br /> ( + <br /> Print Name Date - -. --- - <br /> - -DEPARTMENT USE ONLY- <br /> V , <br /> SITE MAP IN UNIT IV FILE,ADDRESS: t � <br /> WORK PLAN DATED' <br /> / Date Issued <br /> __��/7-:s Area P <br /> A#plErzti�nAa�ptedBy •fes r^ <br /> Grout Inspection ey 4 Date Final Inspection By { Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> � 1 <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY GATE PERMIT I SERVICE REQUEST# INVOICE <br /> C-57 WC -WAIVER C-57.Letter of Authorization to sign permit Encroachment doc .9/27/00 <br />