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11/14/2003 10:09 2094603433 FIFTH FLOOR PAGE 02 <br /> 4. <br /> r ,1 �j�+R u�- ,ALL ,PE•RMIT AP 1 <br /> �� Q <br /> c.�x�IRLIr�i Irri-RTA,ri(EAI.T � SITEPERMIT • <br /> SAN JOAQUIN C6UI"TY P'U Lid IC HEALTH SERVICESMITIGAfifON <br /> 03 NOV -6 .PM 41- 29ENVII.OMN tNTA'L H LTH DIVISION (PHS-F-HD) ' UNIT CV <br /> 304 E. Weber,Third Floor, Stockton, CA., 952012 <br /> • (209) 468.344.9F . � <br /> Nam-Rrz UNDmB PERmrt ERPIRES 1 YEAR FROM PATE ISSUED <br /> ;...,Cation Is trareby made to San Joaquin County fora perfnft to ccnstruct andtar Rhstalt tha work described. This application Is made Orn=rnpllancc with San <br /> oaquin Oaunty Devetopment'ntle,Chapter 9-1915.8 and tho Standards of Sar'Joaquin County Public Health Services,Environmental Hezdth Division; <br /> �G <br /> LkZ `�b 0 s t}bb b Assessor's `� <br /> Vi L Lo=taOn 5�. �tit^'�SL'�R.s-- tt�_ -Cross Street._ - - city_S .��jL'x-� p�G✓LAS Parcel# Qd 7 0 �Q Q �y <br /> -Cortlracterya'- �r'CLA k,4Address ��U ��J-�`1�' Ciry�S\9��+..ZipmLi'o Ptlone�t��b��+1 <br /> ;c`;u1Crf /Slsr `7 nJJ\� c.,9. t a cl r:caAddrsEsr �l X11 $T City LiC# "� Phoned Zl?� S 1 <br /> ;tS coorrdinai=X Y Township Range Section _ <br /> UT X TD IRE Ee-B MED: <br /> tirmr^l WEL /MORIN (CPT,GEOPROBE,KYO ROPUNCH,HAND-AUGER,OT14ER1 1]DESTRUCTION-(choose type below) <br /> 9)SOIL AO RING W _ Q OVER-BORE <br /> a WELL r Tl PRESSURE GROUT' <br /> O er, Grout Specincatlonst <br /> -(r...,lhl FLATS: '4 u f n�'a C2�a 3. 7,���-_ 3 \�i �L• �. <br /> Y"=OF Vv1=LL tPiSTALLATtdNt TYPE CC3N5TRUCTIQN SPECIFICATION$ <br /> I I 7NRTt�RiNG 11 HOLLOW STEM NA.0=BOREHOLE MULTIPLE CASINGS?0 YcS 0 Nb WELL CASING DIES: <br /> I OtrRACTION Q AIR HAMMER/DRIVEN CASING THICKNEESS�TYPE OF CASING; a STEEL Q PVC, 'D OTHER: <br /> I VAPOR .13 MUn ROTARY DEPTH OF GROUP'SEAL,_ TRWMIE TYPE 70 BE USED,. jl AUGERS 0 HOSE <br /> ], i SPARGE U PUSti POINT GROUT SEAL PUtv:PEO: p Yes a No (NOTE: lv1AXlMUM FREE;-FALL DEPTH 18 30'} <br /> *mNL BORING a-HAND ALIGER GROUT SPECIFICATIONS: <br /> j OTHER; Q OTHER A.-PROX BORING DEPTH. j]BOLTED TRAFFIC BOX or II STOVe PIPE <br /> CONDUCTOR CASING PROPOSED? ._-_ _{if YES,list spcci(i�tions here): _ <br /> _ NOTE; OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS- <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN:ADVANCE POP,ALL REQUIRED INSPECTIONS. <br /> I hereby cerEify that I have prepared this applicatlen and that the work Will be done in accurdance Vith San Jcaqtjin <br /> C lnty Ot'�" anc2ss le pd a ulati.o its,and all applicable California Stain Laves. <br /> S) ned x TtlelCom an � N1 \,j <br /> DE-P&LrMENT USE ONLY <br /> r ' <br /> SrrE MAP IN UNIT W FILE,,ADDRESS: ���" C• ��� UJ� <br /> V1 RX PLAN DATED: <br /> Apnf)gtlpn Accapted By. Date <br /> fi it InspscIlon By Data _ __Final Inspa6on By Date <br /> O tmction Inspection By Date <br /> cDn�r��xTs r cor+drrlants ` <br /> ��,COUNTING ONLY: AtQ# <br /> PE CCtPES FEE INFD AMOUNT REM7T1_D CHECK# RECID BY DATA PE>xMIT!SERVICE RFQUEST# INV=E <br /> C-57____ WC -WAIVER C-57 Letter of Authorization to sign perHt i:nrroachment doc_ 9/27700 <br /> ,r EB• �cJdd i:i00',d F'1.L�3'� •' EEhE89t'60Z g4�ET T00z/8i (LL� ' <br />