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• - ---- -_ _'� _ O R I G�I-N-AZ _ <br /> oPnvly SAN JOAQUIN COUNTY <br /> 2�OBADDRESS: 2550 S '�'�94f��4lt p(sSloralttgo C1p,ti5gp2 Il # <br /> • �, a IvrrlTsvrvrvrcmrc�rt,=rc�T-rrvm�T-rT(`l�}� 1 <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 ION <br /> ..aNi Telephone:(209)468-$ C( �,g �g�gtlap✓wsiaov.orgleh <br /> NIT'V <br /> F n_ <br /> Thereby e,C deand�e ua Q!@/prd@yQCO(@C��M'1IIe�l}p�i�Lp1A7PP�Nlslan3of the Business and <br /> Profeea1bam Code and Ia t <br /> . . EI�IYCJI!aBJ�`fD ORINGS USED FOR CONTAMINANT INVr�§jg&T0S All MEDIATION <br /> Date 5/23/12 NON-REFUNDA 1VM IpBnlb iiFB41OftOM DAT - <br /> Application is here y made to San Joaquin County for a permit to construct and/or install the work describ his application is made in compliance ith San <br /> Joaquin CountyD elopment Title,Chapter 9-1115.3,and the Stay NL LVE10001CpAUpephO1rvironmenta He Ith[D1rreT/sa/c/tttin�qyntCCrr��))I'IM IL15--J2o-0$ <br /> Site Location h tJR@✓?�he �� e e Lew for theM'Opw . ,H�IilM1hd dnd,{f55fesslone MID <br /> Property equr tel;-Impro emo re llr6f''��tLdd�'I , <br /> Owner' r �0hh P�r�t,�q'11Ifl�a14Ypd� ^�¢�t t pp��1�,UPgns m t p oft 9 Con <br /> c Rc 'tAllH 5ectla1rF8FIa-of-91�T81ahk�ch'(�$4A RT '!(e'R <br /> C-57 Contractor a 1f7+**096B ARy a o(�6ecticirT"fit nl[gE fi a R'P nl 1�plp <br /> o n no M elan fiv- a I q0):/r p1) <br /> Consultant/Sub [r C reor / ( C )l�d Wr�;il'75fpatean c <br /> Billable Party <br /> as or ops , or m e e s latbe Ih✓i G Apes";; ) 9 I -� Dl <br /> GIS Coordinates. - owner o property o builds or Improves there and who does uch work him ee or rouB ht is ro n e PIT 5,prop i 6 0 Oft <br /> provement offered for Bale, I1, however, the building a Improvement Is sold within one year of <br /> Folt hava the burden of croving that he did not build or Improve(a the purpose of sale.) <br /> CONSTRUCTIOOR TO PERF O MED: <br /> ( I IIy pj�c]�n need contractors to construct the pro)ed(Sedbn 7044,Business and <br /> NEW WELLlA RI , a one a dot ,, `lYEdimN L'EW`doea not apply to an owner d property who builds or Improves hereon, <br /> []SOIL B RINd s Law. <br /> ❑WECL' s <br /> D OTHER I D13 I am exempt under Section B&PCI-orthi3mason <br /> TYPE&#OF WE L/BCHING INSTALLATI <br /> _9 MONITORIN Date; ❑HOLLOW STEM QfA.@4F - Iq <br /> _❑EXTRACTION Vapor/Water D HAMMERIDRIVEN grrtCt�rAppSqIINppG��THHIpI�Caya1KppNEEEqSSggSss yyTIppE OF CASING: D STEEL D PVC D OTHER <br /> C - _ 1 SOIL VAPOR ROBE D MUD ROTARY WGRM"'OF-GRDDTSE�REOMINE TYP TO BE U D' 1'�p S OS O PIPE <br /> art a of Workers' om ensat`fon RIBU ,t <br /> _D SOIL BORING l hereby aR rrDI Ut1 liftil 90 Of CBR �(QI����p�Gas o MAXI M FREE LL DEPTH 1 30 FT) <br /> K - Or *1d <br /> or Co e�. <br /> _ _D INJECTION.(i. t]'� G�rROU,ASPECT <br /> a _D OTHER: EX IIat10n Dej COPRW BOLTED TRAFFIC BOX OR ❑ST VE PIPE <br /> n/p B pY @ONDUC OR CASING D No D Yes:Casing Dia: Casing Depth:_ Boring Di <br /> COMMENTS: ertment <br /> j` NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AG ENT PERMITS <br /> DESTRUCTION-I IORK TO BE PE - DESTRU TO T CHECKALL THATAPPLY <br /> ��J�_#DF W L(S) Q o be co a ed f I I - 1�Ci�Eg r��} FT <br /> IN L IDs: I flawas1Jti�tWNft4f@BBO n'n an�I Fra OW URFACE <br /> . ' .GROUT SPECIFIC TI IFOVIMMOSIVES FROM TO FT BELOW URFACE <br /> TREMIE TYPE TO E - IP "'1' d MUSHROOM CAP AT Q3 FT) FT BELOW URFACE <br /> COMMENTS Applicant <br /> 5 WOR (IN p 6hhq�1e@jpFQlRhfU POINTMENTS <br /> P% Ona0 Ne <br /> h�. I hereby certify th 1 have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, R les and <br /> Regulations;.and a I applicable California laws. CONSTRUCTION LENDING AGENCY <br /> Signed 1 f ga (eh�dR,iaerlo 7 0{ w�orkf ch 1) mit Issued <br /> ,g•_ Print Name Nit e. Date S' <br /> - - Lenders Name <br /> - <br /> •P-f' <br /> -_ SITE MAP IN UNIT Fhigdii r •- <br /> ' t�- WORK PLAN DATE -Z°I-1 2ZVISION OFERMIT CERTIFICATION <br /> APPLICATIONACC PTSD BY ,L.�O#t N't re., e depth Into Whii aOpfpEry <br /> GROUT INSPECTIO B4 I hereby Wffly rl eti7lrflre (al '-mg. to-, n,aolding,fs, �� It I I,tr uva <br /> Ihalzetl by the permit,and that Iraq,bMpd $5( IS glop 1 TI <br /> ,q�r will be rrlore than thlny-ax a eett�Y.'�, <br /> DESTRUCTIONINS ECTI �! DATE <br /> noted <br /> COMMENTS/CONDI 10 R) I. rk whkh would require a permit from t e D e o o fffcWlneFSatetYTea <br /> above Unto"suds poison rise a <br /> ACCOUNTING ONIL AID -Lac# <br /> PE CODES FE INFCTf, ��r1�aT pp age o hg ICE <br /> I be1 etfTleJb�� PePPII IfeM6 to that the 4ReC ystem w^n dhareby u Q1�® e I as t <br /> ordinental i end state lam <br /> l V <br /> so <br /> $1 5 to -man fall <br /> Pups4 '? Ilyabove tl <br /> O'Tk 5z3- RO <br /> . I <br /> # <br /> 3500 <br /> 6�! PR# <br /> J <br /> l922NTTU,CT0R MILIFIFT kITION <br /> C-57 r/ INC isgrItalnVIVAIVER A�[$m C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT L ENCROACHMENT Do <br /> EHD 29-01 5/09112 10i - WELL PERMIT APP <br />