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HEALT ELL PERMIT.APPLICATION FORD SITE <br /> MITIGATION <br /> P�Rz���i :;rRV�C� = - - <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> 03 NOV -6 PM 4: 29ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> A 304 E. Weber,Third Floor, Stockton, CA., 95202 ^ D <br /> (209) 468-3449 ( ) <br /> v <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Vpllcation 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-ntte,Chapter 9-1115.3 and the Standards of Sari Joaquin County Public Health Services,Environmental Health Division. <br /> G 1 , '�b. \o10 b Assessor:' c'� p <br /> Cross Street city S�J�)«,�Zip�S Z><S Parcel# 0a 1 0 <br /> HELL Location ` C� <br /> Lk fit, U 4Li\o <br /> 1° <br /> _\ n Address <br /> ��� a �'� , b c� <br /> PROPERTY Ownar �-�'^ Zip R S 2.1�Phone# ZD�I �l <br /> -1zo�o <br /> C57 Contractor --Address le o (3�'y`�\ city Zs�t�� zip`i E- uc# Phone-# 1'!!. � <br /> "2) D1 '� ST City Clj uc# Phone#Zu9 <br /> Consulta /Sub-6ontrzv�rTS <br /> GIS Coordinates:X <br /> Y ,Township _ Range Section <br /> WORK TO BE _ MED: c DESTRUCTION(choose type below) <br /> (�NEW WEL`/B2 (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 11 OVER-BORE <br /> WSOILBORING# ':\ PRESSURE GROUT <br /> �WELL-_"Other. Grout Specifications: <br /> COMMENTS: YR C- �\ \� ZZ —J '3 .,I3;-\Lf\rn.� <br /> TYP'e OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> D MONITORING D HOLLOW STEM DIA.OF BOREHOLE MULTIPI E CASINGS?D YcS ONO WELL CASING DIA: <br /> 0 E)CrRACTION D AIR HAMM=RfDRIVEN CASING THICKNESS TYPE OF CASING: Q STEEL 0 PVC. D OTHER: <br /> D VAPOR D MUD ROTARY DEPT H OF GROUT SEAL TREMIE TYPE TO BE USED:. 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE D PUSH POINT GROUT SEAL PUMPED: 0 Yes D No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> Q SOIL BORING D HAND AUGER. GROUT SPECIFICATIONS: <br /> D 07HER: DOT H FR APPROX BORING DEPTH . D BOLTED TRAFFIC BOX or [j STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specificatiobs'fiON- s <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 Ord' ancesf,' le - d Wulations,and al�7rti ble California State Laws. (� <br /> Sinned x 5 '—J ZelCompany <br /> Date_ <br /> Print Name c��t <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: '. <br /> A?ea �6� <br /> Application Accepted By Date Issued , . . ` , <br /> Grout Inspection By �/ Date O Final Inspection By ��.r <br /> y <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> C-57 WC -WAIVE;i -- C-57 Letter of Authorization to sign permit Encroachment doc 9/27100 <br /> E0 EJCc a00-13 H1-�IJ EE117E89t*oz 99:EZ T00Z/8L/Z© <br />