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701817/01f/21000 11:16 ^0946834_33` FIFTH FLOOR PAGE 02 <br /> 1 LL RMIT APPLICATION FORM <br /> SITES ` AQUIN COUNTY PUBLIC HEALTH SERVICES MITIGA; SON <br /> ENVIRON, TAL HEALTH DIVISION (PHS-EHD UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDAELE PERMIT EXPIRES 1 YEAR FROM QATE ISSUED <br /> :';cation is Hereby made to Sar,Joaquin County fora Permit to co nstruct and/or install the work desCribeo. T!1i$application is made in compliance wi>:'t Say <br /> coin County Development Tltle.Chapter 9-1118. and the Standards er San Jesquin County Public Health Services,Environmental Health Division, <br /> LL Location Ot W, <br /> 1 <br /> AsSes <br /> odsCroas Street CrrY Parcel# <br /> CPERTY Owne <br /> Address O�, t� <br /> City ZipPhone# O /.— lP_ <br /> 7 Contractor nAddres ,0, _^ <br /> ClZi <br /> pyiCG57 7zo�tR?�ent I i� 7 7 7-y 1 c� <br /> multantISub Contractor� City LJ ~'V <br /> dcresS c] (__�_ hone# <br /> Ccordinatas:X ,Y <br /> Township Range Section <br /> RK TO BE PEf2FORI'AED• <br /> ='N WELL f BORING(C EOPRCBE. HYDROPUNCH,I-AND-AUGER, OTHER'; <br /> SOILBORING <br /> # Q DESTRUCTION;choose type below) <br /> WELL I]OVER-BORE. <br /> 1ef' 1]PRESSURE GROUT <br /> GROUT SPECIFICATION <br /> MMEN TS: <br /> E dF WELL INSTALLATION TYPE CONSTRUCTIQN SPECIFICATIONS <br /> .ZMTORING 0 HOLLOW STEM DIA.OF SOPEHOLE � c <br /> �_MULTIPL_CASINGS?` YES []NO WELL CASING DiA <br /> "r"tF.C"ION E?AIR HA;V;v1ERIDR1VcN CASING THICKNESS TYPE OF CAS(NG:�I`"' <br /> El STEEL 0 PVC ❑OTHER: <br /> [i UD ROT Y DEPTH Or GROUT SEAL TRENItE TYPE TO BC USED: d AUGERS QFt05c <br /> = <br /> SPARGE . uSII Pcl-� GROUT SEAL Puy pED: )(Yes I?No (N TE: MAXI UM FREE-FALL DEPTH IS 301) <br /> :il BORING C3 HAND AUGER GROUT SP=CIF GATION <br /> HER: Q crr;eR <br /> raPPROX_BORING DEPTH 25./ (]SOLTEC T'RAFF)C BCX or Q STOVEPIPE OL)'A- <br /> CONDUCTOR CSSitvG PROPCSED^ IJZ) (if YES,list specifications here): <br /> !.•,TENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> reby certify that i have prepared this application and that the work will be done in accordance with San Joaquin <br /> Inty Ordinances, State Laws, and Rules and Regulations of the San Joaquin County. <br /> "CALL HE UNIT IV INSPECTOR 48 WORKING HRS IN ADVANCE U16) <br /> ALL REQUIRED INSPECTIONS <br /> :dx 9il/\ <br /> O 1 TittelCompanY I h �j`1 i1�1((Jrll'He I <br /> 'flame L Dale <br /> ITE MAP IN UNIT IV FILE ADDRESS !WORE( PLAN DATED <br /> PARTMZNT USE ONLY <br /> :4on Accepte,By <br /> !nSDecdon ey <br /> `'` Date issued 2.- -i/C' _i; _A�.ea <br /> lnspeetion 6y � <br /> Date F=inal Inspection Sy _ Date Z 6�o 3 <br /> =C.iCn Date <br /> -MENTS/CONDITIONS: <br /> :CUNTING ONLY: AID# <br /> -ot I FEE INFO AMOUNTREMITTED .. <br /> CIiECK f REC-D t3Y DATE PERMIT/SERVICE REQUEST 0 INVOICE <br /> Sir `= ,cry I `S - l y �� <br /> -57 .� <br /> WC/WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 7/17/00 <br />