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WE,-. PERMIT APPLICATION )RM UNIT IV <br />SAID} JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION ("PHS-EHD") <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3450 <br />NON-REFUNDABLE PERMIT EXPIRES 1 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 <br />San Joaquin County Development T ttle, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />Assessor's <br />a. Zip `aZ IZ Parcel#��-- 040)-;02 <br />'NEL L Location 'ia14Z-N • i�%�•w � �. �vre�+k..n ross Street 1. � . City , <br />PROPERTY Owner Address`C32o+ ^^ Ptk. D� City =lcf1a:;Zip��Phone# 93%- 0904' <br />S-3�>cz <br />7 Contractor _ LV_'jjn Address -5BS> C-At%6411 CiryLA inn ZipIr k,JLic# hone# (ft)f6g- <br />n 9l6 - -04 <br />Consultant/ Sub Contractor abpAd C—Cpi" ,CanAtddress Cita �o Lim Phone# <br />S4.lt l( <br />GIS Coordinates: X Y Township 'rt" ;Lkt Range y' . Section <br />WORK TO BE PERFORMED <br />NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER. OTHER') <br />SOIL BORING # <br />0 WELL # <br />"Other. <br />:--MMENTS: <br />Pc OF WELL <br />J ,MONITORING <br />0 EXTRACTION <br />0 VAPOR <br />0 AIR SPARGE <br />DESTRUCTION (choose type below) <br />0 OVER -BORE <br />;PRESSURE GROUT <br />CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br />iOLLOW ST^cM DIA. OF BOREHOLE _ " MULTIPLE CASINGS? 0 YESt)KNO WELL CASING DIA: <br />0 AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br />0 MUD ROTARY <br />0 PUSH POINT <br />DEPTH OF GROUT SEAL AQ 'r`�5o 7Z- TREMIE TYPE TO BE USED: `AUGERS GHDSc - <br />vem--GRDUT SEAL PUMPED: `zYes ;2 ',No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />30RING 0 HAND AUGER APPROX. BORING DEPTH &---- ` �5 *iZ' fj BOLTED TRAFFIC BOX <br />or 0 STOVE PIPE <br />'SOIL <br />0 OTHER: CONDUCTOR CASING PROPCSED? ( if YES. list soecrfications here): <br />COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS? <br />hereby certify that I have prepared this application and that the work will be clone in accorclance with San Joaquin County Orarnances, State Laws, and Rwes <br />anc Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: "I certify that in the performance of the work <br />for which this permit is issued, I shall not employ persons subject to WORKMAN'S COMPENSATION Laws of California." Contractor's hiring or sub- <br />contracting signature certifies the following: 'I certify that in the performance of the work for which this permit is issued. I snail employ persons subject to <br />WORKMAN'S COMPENSATIONCalif /a.' <br />T P ICAN UST CALL 48 HRS IN ADVANCE FOUR ALL REQUIRED INSPECTIONS. <br />Signed z <br />Title EE�7t'' D1�09f� { Date A) <br />SEE SITE MAP IN UNIT IV WORK PLAN. DATED r. 09 <br />DEPARTMENT USE ONLY <br />Application Accepted By Date Issued D Area <br />Grout Inspection By_ ._1 <br />Date O 1 Final Inspection By Date <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: I AID# <br />PE CODES I FEE INFO I AMOUNT REMITTED I CHECK»/CASH <br />�-otOl I -�R sq.ODI -A ,DD <br />UNIT IV - 5/99 /MZ <br />ACK <br />RECEIVED BY I DATE I PERMIT/SERVICE REQUEST NUMBER I INVOICE <br />