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��r vim. c.vvi civ..1� LV.I�VV.IY.IJ q r r IF {rf VL-Lryrtl fHVL Vl <br /> IWAVIERM.L.L I ERNUT APPLICAMON �FOR!6- SITE <br /> ,' ,'I NiiTIGA T ION <br /> SAN JUAC iN CU-UN-FY PUBUG HEAL-I H'SER7ViCc,S UNIT IV k <br /> ENVIRONMENTAL HEALTH DIVISION (p,HS-64D) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 4683449 <br /> NON-REFUNDABLE PERMIT EXP ES 1 YEAR FKOW IC Aj�fSSUEQ <br /> ,ppllcubort is hereby rr ode to sai.If acg in du�iy n a Ncviwri irr cor*voct a 1--i6S.^'d.�S'd z'k de::'i�d. Tt!S��'�r�ry;t�$m.��in rprrrQlianCB With San .I <br /> o3quin Csynty Development Trtla,Chapter 9.1115.3 and.the Standards of San Joaquin County Pubo, `Heaiih Services,Environmental Health Division. <br /> -I 1 Assessors <br /> YELL Location ILC/] . EAZ ]'�A,->, Cross Street City 1G� ."�ZiP ¢ 1 <br /> 'ROPERTYOWW1 [ss a/C 7'Zr Address - DOS City)Cac j"cx!7_ip Phone# <br /> / Addrey� zip Lc Phor4D# <br /> :.67 Contractor � <br /> ;ansultant 1 Sub Contractor d4kl Address -,A Q ClyLic#7CJLs WPhone*&yt-3 <br /> I� <br /> iiS Coordinates:X .Y Town3hip Range <br /> VORKTOO PERFORMED: I <br /> ]NEW WELL I BORING(CPT.GCOPROBE,HYDROPUNCH,HAND-AUGER.OTHER-) k i[�DESTRUCTION choose type below) <br /> U 501L$BRING#. / VER-BORE <br /> I]YJELL# It PRESSURE GROUT I <br /> Other: Grout5pedficaUori . <br /> :OMMENTS: <br /> TYPE OF WEt L INSTALLATION TYPE ON TION SPECiFiCATIONS <br /> ]MONITORING [I HOLLOW STEM LIIA.OF BOREHOLE MULTIPLE CASINGS?I]YES 12NO WELL CASING DIA: <br /> ] <br /> EXTRACTION a AIR HAMMERIDRUgN CASING THICKNESS TYPE OF CASING: 1]STEEL a PVC p OTHER; i <br /> ]VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE 70 BE USED: [)AUGERS [I HOSE <br /> ]AIR SPARGE (]PUSH POINT GROUT SEAL PUMPED: p Yes d No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301 <br /> ]SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS: ii <br /> 11 <br /> ]OTHER: (I OTHER APPROX.BORING DEPTH li 0 BOLmo TRAFFIC BOx or Q STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? 11 (it 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 Ordinanrs,Rulewand trl'Aions, and all applicable California State Laws. <br /> Tide/Company l' I <br /> Print Na <br /> DEPARTMENT USE ONLYJ� <br /> I <br /> SITE MAP IN UNIT IV FILE,ADDRESS_ <br /> WORK PLAN DATED: 1I <br /> s <br /> �4 <br /> Application Accepted ByDate Issued Z Area > <br /> Grout Inspection By Date w © Final Inspection a F Dato l <br /> Destruction Inspection By Date I <br /> COMMENTS I C0K0 TIONS: <br /> ACCOUNTING ONLY: AID <br /> PE CODES FEE INFO A1HOI,iNT REFArITSd CHE',K* RECD BY DATE PERMIT;SERVICE RERVE3T IIF INVOICE <br /> i <br /> �d .0o 0o566,6 �[ z�- o� SEWi 00a5 I <br /> C-57 <br /> WC­-WAIVER­ C-57 Latter of Authoriza#ionto sign perra'it—Encroachment doc 9/27/00 <br /> �� U <br />