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02/23/2001 10:05 209468343" FIFTH FLOOR F'pGE'�� - <br /> WALL PERMIT APPLICATION FORM SITE <br /> ,E,IgTIOt+f <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> -EHD) <br /> ENVIRONMENTAL FAooHSokton <br /> 304 E.Weber, Third cGA-, � <br /> (209) 468-3449 D �L <br /> MIT EXPIRES t YE FROM DATE ISSU 0 compliance with San <br /> NON-REFUNDABLE PE is application i3 made In <br /> Environmental Health Division. <br /> ,pplication is hereby made to San Joaquin County for a permit to construct and/or install the work described• S ce Assessors <br /> oaquin County Develo ment Tide.Chapter g-1 115.3 and the Standards of San jJoaquin County Public Nealth Services, Parcetft <br /> ^ rJ�Yvi U city ZiP� <br /> j �� C3 cross Street <br /> NELL Locat]Or �"" —+�---T— D ` �ri� City 5n7Jp�,Phon <br /> j ddress G R0 <br /> ?ROPERTY Owne 5� /yam ,F,9��uic��1J�L <br /> Addrass /y C� jg�p7 <br /> ��Y PhonclfeZ?S-�5 72888 <br /> C-57 Contractor LIct7 — <br /> TviG Address�4 S crr'u C#5••, GitY���--- <br /> Consultant/Sub Contra=, z/ Sectlon <br /> Town3hiP Range <br /> GIS Coordinates:X <br /> Y <br /> WORK 70 BE PERFORMED: �DESTRUCTION(choose type below) <br /> 13 OVER-BORE <br /> a NEW WELL/BORING(CPT GEOPROSE.HYDROPU�N_CH3 3'A'�OTHER-) 0 PRESSURE GROUT <br /> D�OIL BORING a 13 <br /> W ELL# Grout SpeciRcations: <br /> *Other: <br /> COMMENTS: <br /> HYPE OF YYEI_L 1NSTAlt ATION TYPE CONSTR CTION SPECT`I(CATIONS +Np WELL CASING DIA: <br /> DIA OF BOREHOLEMULTIPLE CASINGS• YES • PVC OTHER: _ <br /> 13 MONITORING 13 HOLLOW STEM TYPE OF CASING: 13 STEEL 0 HOSE <br /> AIR HAMMERlORIVEN CASINGTHICKNESSf— AUGERS U <br /> 0 EXTRACTION � TREMIE TYPE TO BE USED: � <br /> VAPOR 0 MUD ROTARY DEPTH OF GROUT SEALS-- <br /> D AIR SPARGE <br /> PUSH POINT GROUT SEAL PUMPED: 0 Yes 13 No (NOTE: MAXIMUM FREE-FACT-DEPTH IS 30' <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: _a BOLTED TRAFFIC BOX or 0 STOVEPIPE <br /> OTHER APPROX.BORING DEPTH I{YES,list specifications here): <br /> 0 OTHER:��a CONDUCTOR CASING PROPOSED?__ I <br /> 'COMMENTS: <br /> ILL <br /> OTE: OFFSITE BORINGS REQUIRE ACCESS OR E FOR ZL ii QU REINSPECTIONS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE a done in accordance with San Joaquin <br /> 1 hereby certify that 1 have prepared this application and that the work will b <br /> ulation and all applicable California State Laws. <br /> County Ordinance ule nd <br /> Title/Company <br /> Signed Date <br /> Print Name DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS:O, / A <br /> WORK PLAN DATED: !p l(L <br /> Date Issued �Q <br /> — Date <br /> Application Accepted By Date Final Inspection By•— <br /> Grout Inspection By 101 <br /> ate <br /> Destruction Inspection By <br /> -0 <br /> COMMENTS t CONDITIONS: <br /> ACCOUNTING ONLY: AIDaK <br /> RECD BY DATE PERMIT!SERVICE REQUEST>x INVOIC <br /> PE CODES FEE INFO AMOUNT REMrrTED CHECK# � ODZS/ <br /> $'� 5 / 9/27/00 <br /> C_57— WC_WAIVER C-57 Letter of Authorization to sign permitEncroachment doc_ <br /> FEB 23 ' 01 10 : 00 2094683433 PAGE .002 <br />