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PERMIT APPLICATION FORM SITE <br /> SAN`:ft�,�f, -1�QUMITIGATIONIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> 04 MAY 13 Wff 9VMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E.'Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> application 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 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> Assessor's <br /> HELL Locations kA £-`�1�Oc S"�. Cross Street �•CC,t�� cityS'rV�k%C�n ZipjS124 Parcel# ILS - Ion -I-I <br /> PROPERTYOwnar'9MX! oti. y4\er,''•,r-e- _ Addressk07,5-- &re CitySk 5ZipC1SZJI Phone# ZO°t q1-13qI I <br /> C-57 Contractory �"WN NIC Address 0 901 11Y` Ul\\V CityZip Lic# Phone#"Abo <br /> Consultant Sa�sentractor�a��7.�nS>,�tc}►M c�Address \\J\1�� S"t Cih ��15`rtJ Lic# Phone#ZO`1 S 2--L 4 11� <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> Q NEW WELL I BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) 0 DESTRUCTION(choose type below) <br /> a SOIL BORING# . Q OVER-BORE <br /> C11 WELL# V E W\ i <;Vt -L E W 1 Q PRESSURE GROUT <br /> 'Other. Grout Specifications: <br /> COMMENTS: SoL..q­ P\a•n <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Q MONITORING I HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?11 YES ONO WELL CASING DIA: <br /> A EXTRACTION Q AIR HAMMEWDRIVEN CASING THICKNESS TYPE OF CASING: q STEEL 0 PVC. []OTHER: <br /> VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED:. Q AUGERS Q HOSE <br /> Q AIR SPARGE Q PUSH POINT GROUT SEAL PUMPED: Q Yes []No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30) <br /> Q SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS: <br /> Q OTHER: Q OTHER APPROX.BORING DEPTH Q BOLTED TRAFFIC BOX or p STOVE PIPE <br /> \_\ CONDUCTO CASING PROPOSED? (If YES,list specifications here): <br /> `COMMENTS: S�9— VV ��Q�erY• �' <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 O finances, ul s a Regulations,and all applicable California <br /> ��State Laws.. 1 I <br /> Signed x 1 \ TFtle/Company 1 i '�o.v.t 'C�� ly� ) k - <br /> Print Name --OJ WJE �� 10 `A WCY�nI Date S / ) O /Jy <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: (1 <br /> Application Accepted By ` , e Issued ��0 Area I I <br /> y' <br /> Grout Inspection By. U Date inal Inspection ByDate��(a z1114 <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE2CODES FEE INFO AMOUNT REMITTED CHECK# R C'D V DATE PERMIT/SERVICE REQUEST# INVOICE <br /> SM Z:2792C-57-___ WC!WAIVER_ C-57 Letter of Autho z to sign permit_Encroachment doc 9/27/00 <br /> E0 ?rJ�d '00-1=1 HiAIA EEbE89b60Z 99:E1 T00Z/8Z/Z0 <br />