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ERMIT APPLICATION RM SITE <br /> E <br /> � �l'V�L�I�r' _ Z1GAT1t3N <br /> � u VQ Mi <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> JAN' 3 2002 ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> ENVIRONMENT HEALTH 304 E.Weber, Third Floor, Stockton, CA., 95202 <br /> PERMIT/SERVICES (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct andtor install the work described. This application is made in campliancs with San <br /> Joaquin County Development Tile.Chapter 1-3-1115.3 and the Standards of San Joaquin County Public Health Services.Environmental Health Division. <br /> lWELL Locationr'Vs3 Vtr LV�Laut' Crass Street .i+',d City zip PS IS Parcel# 14-s-2-6o� <br /> GLC( �Ave City �9 Zip�Phcne# '7 S7 <br /> PROPERTY Owner n �ZAddress <br /> C-57 Cantractor�4f'fI i' Address_j& �V-T� L pp CitY P,� Phan <br /> Cansuttarrt/Sub Contractor Address 4ti' city AXt, <br /> GIS Coordinates:X <br /> Y Township f�nge Section <br /> WORK TO <br /> EW BE PERORMED: � GERf3TtfEt} Q DESTRUCTION(choose type b <br /> elow) <br /> WELL/BORING(CTG OVER-BOE <br /> } BE <br /> 7LBO # Q PRESSURE GROUT <br /> LL <br /> # <br /> 'Other: - Grout Specifications: <br /> COMMENT S: <br /> TYPE OF WELL INSTALLATION TYPE CoNsTRUCnON SPECIFICATIONS <br /> Q MONITORING 1]HOLLOW STEM DIA.OF BOREHOLE____MULTIPLE CASINGS?Q YES Q NO WELL cAstN <br /> Q EXTRACTION Q AIR HAMMERlDRIVEN CASING THICKNESSi <br /> TYPE OF CASING: Q STEEL- l3 PVC Q OTHER: <br /> 11 VAPOR Q MUD ROTARY DEPTH OF GROUT SEAt.�l7'I-+VP TF2>✓iVIIE TYPE TO 13E USED: Q AUGERS 'S'FtOSE <br /> Q AJR SPARGE �USH POINT GROUT SEAL PUMPED: es Q No (NO E: MAXIMUM FREE-FALL DEPTHIS <br /> f �' <br /> OIL BORING 13 HAND AUGER GROUT SPEC1FiCATEPTH Y � rst '`� <br /> [I OTHER _ tI OTHER APPROX.BORING DEPTHy�Q BGLTED TRAFFIC BOX or Q STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (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 /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinance , Rules an egulations, and all applicable California State Laws. <br /> Signed x 1j Title/Company <br /> Date <br /> Print Name <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS. `- <br /> WORK PLAN DATED: <br /> Application Accepted By - '^ <br /> Date Issued b Z Area <br /> �ti'b 414 - ? Final Inspection By r crr Date <br /> Grout Inspection By t� t Date <br /> Destruction inspection By Date <br /> COMMENTS t CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT 1 SERVICE RE-QUEST# INVOICE <br /> 3sat �( .oa IGtacia fi oZ otSSs. g <br /> C-57 yS/C -WAIVER C-57.Letter of Authorization to sign permit Encroachment doc . <br /> 9127/OG <br />