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1u:i-31b"b <br /> I.1Hr-eb-duoc� 0-:it I-KUH: <br /> WE,.L PERMIT APPLICATION I^uRM SITE <br /> MITIGATION <br /> i SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT A <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA-, 95202 <br /> (209) 48B-3449 <br /> NON-REFUNDABLE PE MrT EXPIRES t Y&M FROM DATLISSUED <br /> �Pvl+c+bon i,hereby mace to San Joaquin County lora permit to construct endlor Inaloll the work darcrlbed. 1111 sPPllcation It made In eompuonce w13l San <br /> Joaquin County Development Tlue,Chapter 9-1115.3 and the Standards of San Joagvin County Pvb110 Health Services,Pnvfronnlent2l 1-10310 Divili(m <br /> /'l Asaes,orc <br /> NELL Location -Ar.7-0 Ad (Jo0P0,q%ObG a Cross Street *`� 95N City a[a^ QO 2hp �s Parcelu p/7��-OOL <br /> �1tio Kerrca <br /> 'ROPERTYO+mer/�NJcwen �p,vc�../s. A,ddresc 20 C;ryr•?vvs�vE ZIpE1�F'l,oncR .� <br /> C-57 Contractor, (t <br /> _ J(7o�`I_/u')C(1 d ro Gry Y Zip_ )C# Pha <br /> Consultant/Sub Contractor Q k-. SeVPl9Cj1L R E AdAres9 L,cg 6-21210 Phoneu <br /> GIS Coordinates-X ,Y ,Township Range 7C Sectlon <br /> YORK TO BE PERFORMED; <br /> ANEW WELL/BORING(CPT,GEOPR08E.HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose typo below) <br /> 6SOIL BORING p Oki _0117 p OVER-BORE <br /> Q WELL>Z %PRESSURE GROUT <br /> 'Other: Grout SpouflcaUons� Q <br /> COMMENTS. - <br /> TYPE QF WALL INSTALLATION TYPE OONSYRUCTTON SPECIfICATIOND <br /> U MONITORING p rtOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINOS-)()YES ONO WELL CASING DIA. <br /> D EXTRACTION 0 AIR HAMMFPVnIVEN CA31NG THICKNESS TYPE OF CASINO! p STEEL- p PVC 0 OTHER. <br /> 0 VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TG BE USED. p AUGERS [t H05F, <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: [)Yes ON. (NOTE. MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING p RANO AUGER GROUT SPECIFICATIONS: <br /> 0 OTHER n OTHER APPROX.BORING DEPTH_ _. 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED-). (if YES.Ilsl spaclricaGon,hers); <br /> 'COMMENTS: <br /> NOTE: FFSITEB NGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE SNIT )V IN P OR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. �4 <br /> I h eby cert y hat 1 h o If tared this application and that the work will be done In accordance with San Joaquin <br /> C unty Orm s, 1 s d egulations, and all applicable California State Laws. <br /> xr itined x —TI(letcompnny 9NoN&C-ii, 0t 0PCeYMRrNS 069r15r,J D- <br /> r '�►Cv� ,,tom.,c <br /> OM Na C+1R�S (r)h�+crL- Dote-S-20 •Dz <br /> DEPARTMENT USE O LY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application A=ptW By '\ 1 I <br /> Date I-Sued V •:.; Area <br /> Grout lnpe6hon By <br /> Data -Final Inspection By <br /> Dau <br /> oealrvction Ins ealon 8y Oats <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY- AID# <br /> PE CODES FEE INFO AMOUNT RFMITTFD CHECK✓r RECD BY FDATE PERMIT I SERVICE REQUEST A INVOICE <br /> C•57— WCC WAzVER__CC_57 Letter of Aythor' 1'9;1t rt cg t­Encrocichrnent dor__ 9/27/00 <br />