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#_4 PERMIT APPLICATION FORM <br /> t.E �lif�vfi�f �i � �fE SITE <br /> r�- �P .AN JOAQUIN COUNTY PUBLIC HEALTH SERVICES LITIGATION <br /> PM JENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> 03 SEP 23 <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 �� <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Vpllcafion 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 /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of Sari Joaquin County Public Health Services,Environmental Health Division. <br /> NELL Location O "\ - ( Assessor`n^a r Cross Street � � city Pas Zips 2J_ Parcel#_1 \1 1,o-I - Ig )-D I <br /> PROPERTY Own <br /> `er1 SS �w\L }�1 (I�� A AQddre1sts�C�o Z - `y,� . ,{ City S�o cCIC � zip ISZo7 Phone# `-1 Z S(4 <br /> C-57 Contractor \Ar\fv �X" Address_>� VJ.3 �' City !LS 1 +21 Trp l SG4I Lic#�Z0 by Phonalf_QI b 7-7 1 u <br /> onsulta /Sub Contractor !'1 'Q-'- aAddress \" {� ST City ) Lic# — Phone#_2-0'( Zz`411°I <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION(choose type below) <br /> a SOIL BORING# (}OVER-BORE <br /> SWELL# '�Da- Q Grout Specificati PRESSURE GROUT <br /> *Other. ns: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> !I►MONITORING 4 HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?O YES ONO WELL CASING DIA: <br /> 1!EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: Q STEEL p PVC. 1]OTHER: <br /> 0 VAPOR - .0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED:. p AUGERS p HOSE <br /> 0 AIR SPARGE 1)PUSH POINT GROUT SEAL PUMPED: p Yes t1 No (NOTE: MA)CMUM FREE-FALL DEPTH IS 30'} <br /> p SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br /> Q OTHER: 0 OTHER APPROX.BORING DEPTH &BOLTED TRAFFIC BOX or [j STOVE PIPE <br /> c CONDUCTOR CASING PROPOS-ED? (if YES,list speaficad s here): <br /> *COMMENTS: _OJ.R_. '� �c��s Q� \� (�\Gv�s ��)3�4"Z � 1 0 2- <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, Ru es aan� Regulations,and all applicable California State Laws. l� <br /> Signed x <br /> Print Name \`may f���� �"•b�a n�i �J <br /> Dat.. <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED:--2,7 U04 7.00Z zZ aik,,,ide) by cyP 4.jdtuo4v lX117 e3 <br /> � � J <br /> Application Accepted By // � e/��/C�/Sam Date Issued � 3 Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY. AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3501 AW $9- 0150yZ— C!JiR 9 .2303 0p 3G 17- <br /> C-57- <br /> 2C-57_ WC -WAIVES C-57 Letter of Authorization to sign permit_Encroachment doc 9/27/00 <br /> E0 ?JGd sJ00�� H1�I� EEbE89b68Z 99:ET TOOZ/8Z/ZO <br />