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RA <br />WELAERNIIT APPLICATION FO <br />PE CODES <br />SITE <br />AMOUNT REMITTED <br />PAYMENT MITIGATION <br />REC'D BY <br />RECEIVE(_) SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br />1 OICE <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />MAR 14 Nal 304 E. Weber, Third Floor, Stockton, CA., 95202 <br />n►3 117 <br />(209) 468-3449 <br />SAN JUAOUIN COUNTti' <br />PUBLIC JENTH�FRVICF`; <br />:NVIROVEr1T° NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />application Is ereby 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 />i S Z. Assessor's <br />HELL Location /^) �'l� ��, .1. i1 r.,Z Cross Street .. 3: rel iu� CityI t w L-) zip Parcel#_ 2 �,�; �L O u i <br />n <br />IIWe , <br />13ROPERTY Owner S', C- Address 3 l K O \N �- nr ��� City C Mk- _ Zip S 3 76Phone# 6 <br />� <br />C-57 Contractor 'VA y, �) l- �\\ % ,ti Address ? "� Phone# <br />Consultant /Sub Contractor �' o' v„ : y�� a ^ `Address City c# Phone# <br />GIS Coordinates: X Y , Township Range Section <br />WORK TO BE PERFORMED: <br />[) NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER`) a DESTRUCTION (choose type below) <br />[] SOIL BORING # [] OVER -BORE <br />WELL # [ [] PRESSURE GROUT <br />*Other: Grout Specifications: <br />COMMENTS: Ss .. �° c'� C, Vv{ v �`N- il � cw,. C'\'t --a L1tn�r.l <br />R <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />MONITORING 11 HOLLOW STEM DIA, OF BOREHOLE MULTIPLE CASINGS? 0 YES ONO WELL CASING DIA: <br />[] EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING [] STEEL j] PVC [] OTHER: <br />d <br />[] VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: [] AUGERS [] HOSE <br />[] AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes [] No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />j] SOIL BORING a HAND AUGER. GROUT SPECIFICATIONS: <br />[] OTHER: [j OTHER APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or [] STOVE PIPE <br />t. CONDUCTOR CASING PROPOSED? ( If YES, list specifications here): <br />*COMMENTS: -Z•_ ^\ `C Y1 1 - C) C) <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 Ordinances- Rulels attd F4eug lations, and all applicable California State Laws. <br />Signed x Title/Company�— <br />Print Name �1,1\O�• G�p�g1 nv ^ _Dat,eZ— <br />J DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 3 _:-R O i I`tn v. e rz-aekelf <br />WORK PLAN DATED: 4 <br />I t <br />Application Accepted By Date Issued 7-- _Area <br />Grout Inspection By r Uva Date �I L G �- Final Inspection By _ Date l <br />Destruction Inspection By Date <br />COMMENTS ! CONDITIONS: <br />ACCOUNTING ONLY: ONLY: AID# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PERM RVICE-REQUEST # <br />1 OICE <br />3 �v ► <br />�g.�G <br />n►3 117 <br />C-57^ WC; WAIVER_ <br />C-57 Letter of Authorization to sign permit_ <br />Encroachment doc <br />9/27/00 <br />E6 39bd <br />i1007._� HLIA <br />ECVEE9VG9Z 95:ET <br />T0GZ/9Z/Za <br />