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ORIGINAL <br />'1f'VELL PERMIT APPLICATION FORM SITE - <br />SAN JOAQU'IN COUNTY PUBLIC HEALTH SE VICES MITIGATION <br />ENVIRONMENTAL HEALTH DIVISION (PHS4UNIT IV <br />EHD) UNIT <br />304 E. Weber, Third Floor, Stockton, CA.., 95202 UReGG D� <br />(209) 468-S"9 <br />NO RIErUNDABLE PERMrr EXPIP.ES I YEAR FRtJM SATS SUE[► C - <br />Ft <br />r� plic�r:;ri is hereb,v :Wade to San ,!a24u,n Countj fora permit to ;I,e work described, Thia application i-5 made in compliarro with Sar, <br />io4qu'rf C,00nty Qt;veioprnent *nue, Ghcpter rr1715.3 and the Standar:.~ of San ..oaquIn County Public Health Senioes, Environmental Hetaith Division. <br />/ o Gf Dc l�ssessar G�3.Z <br />iti�eLL Lucaticn ` �*'�--Grose'Street _/ �__Cliy G-Z;p Parcel; <br />� <br />FR0F'EF;'' e OwneI L9 Addre55 ��C t'(cL�/IcC �Ci!y ���i/� �� ZipFaf Phone# <br />c <br />C-_5? Ccnt'actor /��[flcAek Addre5{ ,�, <br />Cansal:ant / S;rb C,.r.tr-ctory "`7 ���`^— Address 3d �% �a C city �Llc#OUD Phone#LL <br />I <br />c3iS Caa �r::•ate:s: h , YJ� , Tcv+mship Range. 5actian <br />WORK TO. PERFOF;M1oU — <br />WEvv VYIELL / SCIPi diGGEOPROBE, HYDROPUN!CH, HAND -AUGER, 01HER-) <br />[; $CIL BORING ' = <br />0 "IF -LL # ! — <br />Gmut SpecAlcabans;_ <br />':SQA"' 1EN T Sr <br />n yF`E 2F WE.Lt_ WSTALIA 7170N TfPE <br />`J� MONITOR!NG U HOLLOW STEM: <br />0 E,'KTP,P,CTION, 0 AIR HQ MEF:'t'RIVFN <br />0 v4POR 0 MUD R07A> ;Y <br />5 Tile SPARGE POSH POINT <br />D SGML 00x7 !N -G �' 0 'HAND AUOu R <br />•CO MMEN <br />CQNSTR.:.ICTION SPECIF!CATIOWS <br />(j DESTRUCTION (choose type below) <br />Q OVcR-BORE <br />11 PRESSURE GROUT <br />01A_ OF BOREHOLE �_ NU. TIPL E 0 YE$ P(NO WELL CASING DIA:_ <br />CA.$!1\'3 THICKNESS_— STYPE OF CPAING: 0 STEEL 0 PVC Q OTHER: <br />DEPTH OF GROUT CEALL _ TREMIE TYPE TO BE USED' 13AUGERS 0HOSE <br />GROUT SEAL !°QMPEr;-)("es 0 Fdo NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />GROkjT SP_`F!CATI'7INS:—_ <br />APPROX. BORING DEP fH,Ik5 !] i I3OLTEO TRAFRG BOX or a STOVE PIP! <br />CONDt_IGTCR CASING PROPOSED? NO ( ijYES, ilst specifcat3ons here)' <br />NOTE: Cit~ FS1TE B RiIrI S ('�EC�IlaRE ACCESS OR ENCROACHMENT PERMITS, <br />CALL THE UNIT IV "dCIPEG*UR 48WORKING HOURS IN ADVANCE 170R <br />i hereby certify that i have pMepar,&d this application and that the work will be. � <br />County Ordii rI a Rules a Regulations, and all applicabie California State <br />Signed X _ _// TifleiCompany � <br />P'in' Name <br />to Tall � w.mn.�aaa! a aa.av .aeaa 4J <br />S;TE MAR IN U T IV' FILE, <br />WORK PLAN DATED. <br />n.Pp:'k;&tion Accepted E <br />Grout InSpPot; ?r L,a— <br />Dvstruction insoactior. <br />COMMEN—S 1 eCON011TIONS: <br />A0 3 <br />! - ea. - <br />(o —21, —O 2 <br />Date <br />Date_ _ Fina: Inspection By <br />Date <br />i, ACCOUNTING ONLY: A r'r#I rni�a+ I <br />RE=QUIRED INSPECTIONS. <br />in accordance with Sari Joaquin <br />"�r <br />o A <br />/Z-3 -O Z. <br />V� <br />/—(a "1i <br />rPF CODES <br />FEE INFO i AMOUNT REMITT'ZD <br />CHECK # � REVD $Y <br />DATE —� ST # INVOICE;r <br />5L <br />2 03.0 <br />C- vile. ✓ -WAIVER_ C-557'" .tter a Aut!a or zu Eat tc sign permi# — r�E�Q rh►n nt �t f_ _ �!Zii0i <br />