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I <br /> !►SELL PERMIT APPLICATION FORM <br /> SITE <br /> MITIGATION <br /> SAN jOAQUItI COUNTY FUBLIC HEA H SERVICES UNIT IV <br /> } ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> --NLTy 304 E. Weber, Third Floor, Stockton, CA., 96202 <br /> (209) 468-3449 <br /> NON-RCPUNDAMLE PERMfl EXPIRES 1 YEAR FROM LATE ISSUF <br /> tpplical;Qn i.;hsraby madc to Caur:ty for o permit to cens,rue on lar install the work described. Ibis appiica;Ion is made in rnmpllance with San <br /> InaQu1n County Develcomcnt Tioe.Chnptilr 9-1115.3 and the Srandards of San Joaquin County Public Health'Services,Envirwimentat Health Division. <br /> i i' As <br /> HELL Locallan la G (1 Cross Streel v. Ci 7i ! <br /> C h �^ ty�/,`�' l p-���ParCEst# — -o <br /> f IROPERTY Owner Address 9 v City"fc �ffi� Zip phone# <br /> -37 Contractor �� a f o)C 3 oe a <br /> - ...�U —,« Address 1 0 3 ,tpyStiFE_ _-9 Phone# o�3 3 d <br /> :onsultant/Sub Contra Cor u/ Addrrss j l�i'7� 4 t11�I�ou t-Le -, ^LiclF Phone#q 16 X53�OZ,7 <br /> 315 Coordinates:X Y_ To%nshlp �l Range_ - - Section <br /> s MORK!—QgPERFORMEQ�_ <br /> l —S iEW WELL I60RING(CPT.GEOPROBE,HYDROPUNCH,HAND-AUGER.OTHER`) p DESTRUCTION(choose type below) <br /> D SOIL BORING# 0 OVER43ORE <br /> a WELL#_ i; 11]PRESSURE GROUT <br /> 'Other: Grout Specifications. <br /> :�OIMMENTS: Ip <br /> DTk-QF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> / MCNITORING [ OLLOW STEM DIA.OF BOREHOLE_Z _MULTIPLE CASINGS?0 YES ONO W ELL CASING D1A:. y <br /> ]EXTRACTION [I AIR HAMMERIDRIVEN CASING THICKNESS TYPE'OF CASTING: Q STT_EL p PVC l3 OTHER: <br /> VAPOR U'MUD ROTARY DEPTH OF GROUT SEAL I�'TREMIE TYPETO 0E'USED: ElAU0SRS U HOSE <br /> ]AIR SPARGE 0 PUSH POI Nr GROUT SEAL PUMPED; 0 Yes [i No (t'JOTE: MAXIMUM FREE-FALL DEPTH FS 30') <br /> ]501L GORING 111)AND AUGER GROUT SPECIFICATIONS' ii <br /> R OTHER: — ' <br /> - 10 BOLTED TRAFFIC BOX or p STOVE PIPE <br /> CONDUCTOR CASING PROPOSEO? (if YES,list spedfiicaCtons nore): <br /> 'COMMENTS: I; <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL TfIE UNI r IV INSPECTOR 48 WORKING HOURS IN ADVANCES FOR ALL REQUIRED INSPECTIONS. <br /> f I hereby certify that have preps,red this application and that the work will be done in accordance with San Joaquin <br /> County rdin s, Rules Regulat ons,and all applicable California State Laws. <br /> ii <br /> Signed x Title/Company_LIC_Y %'c.'!!mz e-. -1 ` [ • T�2 C?�/c/ L <br /> tri mesoZD Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: 1%0 Im <br /> �1 <br /> i' <br /> Appiicalion Accepted By Date Issued+` 1 `I D Area <br /> Grout Inspaction 8y Date I Final Inspection By Da tE f <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: I� <br /> S <br /> ACCOUNTING ONLY: AID# <br /> FArg <br /> PE CODES FEE INFO AMOUNT RFM17TED CHECK# REC'D BY VATS it PERMIT 1$F-RVICE REQUF*T 0 JNVOIGE= <br /> 3 So �S�A1✓ Doi z DO S za <br /> C-57T WCC WATVER_ C-57 Letter of Authorization to sign permits Encroachment dots. 9/27/00 <br />