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02/23/2001 10:05 209468343" ' FIFTH-FLOOR <br /> FILE <br /> lLJ <br /> WALL PERMIT APPLICATION FORM SITE�A R ' 9 200 r,, <br /> MITI74:0�O Cif 1 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT f`,`'`�`+�.�,I_. <br /> HEALTH DIVISION (PHS-EHD) <br /> ENVIRONMENTAL <br /> C 95202 <br /> 304 E.Weber, Third Floor, on, <br /> �� �OS <br /> NONREFUNDABLE PERMiT EXPIRES 1 YEAR FROM DATE ISSUED <br /> tandards of an Joa On County Public Health Services.Environmental Health sesso SDlvision. <br /> PP <br /> ?/cation is hereby made t0 San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with an <br /> Joaquin County Development Tide,Chapter 9-1115.3 artd the S Zip Zo. Paree►if <br /> Q�/ Cross Street City <br /> JYELL Loeatlo(� t/ yt ZjP_�Phone# ✓ I <br /> Address 7 <br /> PROPERTY Owner' �1 �1Zip �Lhoneay <br /> City_ <br /> Contractor Address ��77O?9 Phon <br /> <G'rt City v nH LICA�� <br /> r.�Thc�Addr Section <br /> Consultant I Sub Contractor �i'_ Range <br /> GIS Coordinates:X <br /> Y ,Township <br /> WORK TO BE PERFORMED: Q DESTRUCTION(choose type below) <br /> (]OVER-BORE <br /> Q NEW WELL I BORING(CPT.GEOPROBE.HYDROPUN H,HAND-AUGER,OTHER'S Q PRESSURE GROUT <br /> SOIL BORING a <br /> p WELL� Grout Specifications: �" '�� <br /> *Other: <br /> COMMENTS: <br /> TYPE OF WELL MSTALtAT10N TYPE CONSTRUCTION SPECIFICATIONS NO WELL CASING DIA: — <br /> DIA OF BOREHOLE+-MULTIPLE CASINGS. Q YES (] OTHER: <br /> Q MONITORING 13 HOLLOW STEM TYPE OF CASING: 13 STEEL Q PVC Q <br /> Q <br /> EXTRACTION 13 AIR HAMMER/DRIVEN CASING THICKNESS —. TREMIE TYPE TO BE USED: 13 AUGERS Q HOSE <br /> Q 11 MUD ROTARY DEPTH OF GROUT SEAL <br /> FAIRSSPARGE Q PUSH POINT GROUT SEAL PUMPED: Yes No (NOTE: MAXIMUM FREEFALLDEPTH IS 30 <br /> VAPOR Q Q <br /> HAND AUGER GROUT SPECIFICATIONS: �BOLTED TRAFFIC BOX or p STOVE rlrE <br /> 0 SOIL BORING APPROX.BORING DEPTH <br /> p OTHER:�_Q OTHER if YES,list specifications hers): <br /> CONDUCTOR CASING PROPOSED?_ <br /> 'COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS O CE FOR AL CREDU RED INSPECTIONS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE <br /> hereby certif that 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> 1 he y Y ulatio , and all applicable California State Laws. <br /> County Ordinance ui land R g G - � �C��t' -���'`' "Z'C- <br /> TIUe/Company ' <br /> Signed x Date,V/ /V <br /> Print Name DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,AD2ESS: <br /> D <br /> WORK PLAN DATED: 3 O �0 <br /> ate <br /> Date Issued i � Ov <br /> � <br /> Application Accepted By Oate Final inspection By <br /> Grout Inspection By Date d Z� <br /> Destruction Inspection By <br /> COMMENTS I CONDITIONS: <br /> [ACCOUNTING ONLY: AIDA PERMIT I SERVICE REQUEST Jf INVOICE <br /> RECD BY DATE CODES FEE;INO AMOUNT REMrfTED CHECK r /501 S '� 9/27/00 <br /> C-57,^ WC;WAIVER_ C-57 Letter of Authorization to sign permit-Encroachment doc� <br /> FEB 23 '01 10 :00 2094683433 PAGE .002 <br />