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i <br /> -1 <br /> copy <br />{ man Joaquin ountyNL�� t 7 z' 1 ''�=' - <br /> nv�rn ntalalth spa int � , ��1 t� 1TE <br /> 600 East Main Stl eet, Stockton,Cts 95202-3029 � fATI N <br /> IUL <br /> (209)468-3449 Fax:(209)468-3433 Web:www.sjgov.org/ehd 2010 UNIT 1V <br /> eH Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 9 YEAR FROM DATE ISSUED j f�`� t'1r;� `y j I o W .,5 <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 San <br />! J q County Development Title,Chapter 9-1915.8 and the Standards of San Joaquin County Environmental Health Department. <br /> t /� 1 Glx . C cc-e. 7' N <br /> Assessors <br /> WEl4C L tion Crass Street c . City Zip Par <br /> PROPERTY <br /> I Owner ['AL71ZjJr 1 Address'_'_ � City'�7V44::r7VA) Zip?5�YPh T '6 1a<?;,f ��Y ✓ <br /> C Contractor, Aip�E713laC8110Phone# � � a36 <br /> ll(-7 <br /> ? <br /> Consultant/Sub Cntr t11,t. &4 Address 49#'IZ � y �rp4� 'yCityA#—r!` v uc#e,5'7?0? Phone# f16 /,'`� ��'4 <br /> GIS Coordinates:X Y °""t 2 I.� ' Township TT Range <br /> _Section.I <br />{ WOMTOBEP O <br /> 0 NEW WELL 1 BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) DESTRUCTION (choose type below) , <br /> "SOIL BORING# 0 OVER-BORE. DIAMETER <br /> ,WELL PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMENTS: Akt nnVL rY - <br /> TYPE OF MELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING VHOLLOW STEM DIA,OF BOREHOLE rsr 0 MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS S''l H0 TYPE OF CASING: 11 STEEL PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 415E,' TREMIE TYPE TO BE USED: 0 AUGERSOSE <br /> 0 AIR SPARGE!OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Yes 0 No (NOTES MAXIMUM FREE-FALL DEPTH IS 301) t <br /> j 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS 57-ra IO r IV 6 5A4k Or 45,rq <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH z: �OLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR 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,Rules and Regulations,and all applicable California State Laws. <br /> Signed Alz �� � Tltf�rtCCompany jL�'Cr 64"'1l� c-,i5ig <br /> Print Name /�} (�F i t E t A CH Date <br /> DEPARTMENT USE ONLY <br /> SITE MAF IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issuedrf Area <br /> Grout Inspection By Date i i FinallinspectioniBy Date � t 6 <br /> Destruction Inspection By Date <br /> COMMENTS!CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK 0 RECD BY DATE PERMIT J SERVICE REQUEST# INVOICE <br /> �tlltAV49 L 2.. 1_s 1A & f () 1 <br /> C-57 WC -WAIVVER® C-57 Letter of Authorization to sign permit Encroachment doc-- a <br /> EHD29-02-001 WEB fc f <br /> 911112007 1C)t�"" UFJ V <br />