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r NVIR0111 NTAi. HEALT ELL PERMIT APPLICATION FORM SITE <br /> £� MITIGATION <br /> PFR.1-E i :I�RV�C� J. <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> 03 NOV -6 PM 4: 2 9ENVIRON MENTAL HEALTH DIVISION (PHS-EHD) <br /> 344 E. Weber,Third Floor, Stockton, CA., 95202 <br /> (209) 466-3449 y <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> V;jllcation 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 9-1415.3 and the Standards of San Joaquin County Public Health Services,Environmental HeaAssessor's <br /> sDivision. <br /> �1b <br /> ' 04, LjbZb Clty S� ztp°l5 LAS Parcel# 0137 0 q a L 10 <br /> (FELLLocation tom. Ch�e�oL�S Q Cross Street (� <br /> PROPERTY Ownar\�n �r�a��'�r', Address�b 3 C S o��-�a^ Zipg SZ15 Phone# ZG�I f (� O <br /> `! 1z,oq o� <br /> C-57 Contractor V �•; �(t�\1.�_Address L� `�� City ZS�9�o•� Zip -A) Lic#I Phone#�1b111 �LD gi <br /> tv c1-0 Uc# Phone#109 SzL�1I� <br /> Consulta I gabfmntr�tar ����"°�'�`�- `L�`^`cddress 1 "\ ST Ci <br /> GIS Coordinates:X_ - <br /> Y Township Range Section <br /> WORK TO BE�IiS <br /> _ MED: DESTRUCTION'(choose type below) <br /> { NEW WEL IN (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') p OVER-BORE <br /> W'SOILSORING# °� - 0 PRESSURE GROUT <br /> WELL# <br /> *Other. Grout Specifications: <br /> COMMENTS: Y s,r �t\'' iZ 1Q) , ZZ-'3 -" id 3 :-k<- <br /> TYPE-DF <br /> LTYPE F WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING B HOLLOW STEM DIA,OF BOREHOLE MULTIPLE CASINGS?DYES Q NO WELL CASING DIA: <br /> EXTRACTION 11 ALR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: Q STEEL 0 PVC. D OTHER: <br /> p VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED:. 0 AUGERS GH OSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes T]No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOILBORING I]HAND AUGER. GROUT SPECIFICATIONS: BOLTED TRAFFIC BOX or D STOVE PIPE <br /> p OTHER: D OBER APPROX.BORING DEPTH . D <br /> CONDUCTOR <br /> l _ CASING PROPOSED? (if YES,list specifications here): <br /> `COMMENTS: `�Z j �c "K l O 1, . O 3 <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 /> Count=Oances4TAle�djegulations,and alI applicable California State Laws.x TltlelCompany <br /> Signed <br /> a `��� � ` <br /> o �� �l Date <br /> Print Name \ 3 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: D- <br /> Application Accepted By Date Issued Area <br /> Grout Inspection By <br /> Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK.# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3 lad <br /> C-57_ WC_ _WAIVERC-57 Letter of Authorization to sign permit ZEn.croachment doc 4/27/40 <br /> E9 39d6 X1007A H13IA EEt'EB9b60Z 99:ET t09Z/BZ/Z0 <br />