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S <br /> 04-20-2001 03:40PM F TO� 191 IF JU COPY <br /> t <br /> VIECL PERMIT APPLICATION FORM <br /> 1JOlp SAN:JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHO) JAY_ MX03 <br /> 304 E.-Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 ENVIRONMENT HEALTH <br /> PERMIT/SERVICES. <br /> NON-REFUNfaABLE <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application Is hereby made to San Joaqulh County for a permit to construct and/or instaii the work described. This applicatbon Is made in compliance with San <br /> �Joaqua t, ty Development Title,Chapter 9-Z 155.3 and the Srar�dardt of San Joaquin Conry Pvbft He4ltfi Services,En�ironment2l Naalth Division. <br /> fry to Assessor's <br /> WEtt Loeatlon to S" iP etFtc a)('5. Cross street ftG1­0�5- 120 City 5MttG�rans zip rt S�y7 Farce(#F 97-910 r3! <br /> 74 L.wcer.nltis zl !Et!7 Ih ne# go 01% <br /> 8-tZo <br /> PROPERTY OwnerLrNGoL0 ?L%P6r�tWE t:�i0 Address ��� CItY�- --�--- p <br /> C-57 Contractor rseAddress `� slfEAiS 15 CltyAal p `a?L�as6b386�pnon,4L--!t 77->--X570 <br /> 3o3 -flAosecer A4a� <br /> Gonauttartt 1 Sub Cantractor�tx T�Ar�S Nc. Address t�2 et 40 CityLids phonef�9��853-1 Bao <br /> GIS Coordinates:X t Y ,Township Range Section <br /> &ORK10 BEFEREQRM DESTRUCTION(choose type below) <br /> ,&NEW WELL/BORING(CPT. EOPROBE, YDROPUNCH,HAND AUGER,OTHER") 0 Lt a 13 OVERBORE <br /> (] G# <br /> • Q WELL# D PRESSURE GROUT-Other. Grout Specifications: <br /> COMMENTS, <br /> TYPE Of WELL �TALLATION TYP U N T TION P IF T b 3 <br /> Q MONITORING Q HOLLOW STEM DIA.OF BOREHOLE /.5"' MULTIPLE CASINGS?D YES 9NO WELL CASING-, t�„!+4_ <br /> [I EXTRACTION 1]AIR HAMME=R/DRIVEN CASINd THICKNESS eV A- TYPE OF CASING-. a STEEL EI PVC Cl OTHER <br /> U VAPOR p MUD ROTARY DlFPTH OF GROUT SE=AL 0—n TREWE TYPE TO BE USED: I]AUGERS Q HOSE <br /> CI AIR SPARGE XPUSH POINT GROUT SEAL PUMPED: n Yes a No {NOTE: MAXIMUM FREE-FALL DEPTH IS 301 <br /> -gSOIL BORING O HAND AUGER GROUT SPECIFICATIONS: NE4 C.fe"E0- <br /> I3 OTHER: n OTHER APPROX.BORING DEPTH 3's , D BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? Pr (if YES,list sp&dficatlons here): <br /> -COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL TI1E UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> 1 hereby certify that I have prepared this application and that the work Will be done In accordance with San Joaquin <br /> County Ordinances, Ruulle{s� and Regulations,and all applicable California State Laws. <br /> Signed T'rtlelCompeny SE�-r SGrEnli7 ri .t5 �NCc <br /> i Print Name �� � Date — -0 <br /> DEPARTMENT USE/ONLY <br /> SfY"E MAP IN UNIT IV FILE,ADDRESS: (C� ZS [ 'L NON—wp <br /> WORK PLAN DATED' <br /> Ilasuad v" �/ A►wa <br /> i Appiicatian Accepted By, Date <br /> Grout Irapection By Cate Final Inspaction By Date. <br /> i Desfruc�ion.lriapec8on By Data <br /> I It <br /> COMMENTS f CONOlTIONS: <br /> ACCOUNTING ONLY: AILT# <br /> ! PE CODES FEE INFO AMOUNT REMITTED CHECK I! RECD BY DATE PERMIT 1 SERVICE REQUEST 0 INVOtCE <br /> Ul <br /> C-57WC=WAxVER— C-57 Letter cf Authorization to sign permit,Encroachment doe 9127/00 <br /> TOTAL P.04 <br />