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04/25/2002 09:03 2094683433 FIFTH FLOOR PAGE 02 <br /> 02/19/2002 16:12 2094683433 FIFTH FLOOR <br /> PAGE 02 <br /> PERMIT APPLICATION FORM SITE <br /> 02 <br /> P22 P'4 '�q SAN JOAQUIN COUNTY MITIGATION <br /> EN44NMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> ' 304 E. Weber, Thirst Floor, Stockton, CA, 93202 <br /> (209) 468.3449 <br /> NON-REFUNDA9LE PERMIT EXPIRES 1 YEAR FJ DATE ISSUED <br /> two h hereby made to San Joaquin County for a Permit to construct endfvr install the wont described. TFtis application is made In compliance with San <br /> in COonty D¢volopment Title,Chapter 3.11 i6.3 and the Standards of Son Joaquin County Environmental Health Department. <br /> Location /1/q(4/ i Sjt l4 0 Cross StreetA6sessoec; <br /> _ N-�C'h`d�tiL�P ParceH1_a0S-Q?O �1$ <br /> ERTY OWner <br /> , lts .. <br /> 7 Contractor 4r2M^Ar Address msp9S3 f/_ <br /> Phane#_-�"-S79r-.79t'g <br /> A" <br /> 1 ,�I�' Lias Peon 7iY <br /> Rant/Sub Contractor -r-r /I..i .. --A Address13 &&.0I y 1City <br /> Coordinates) Y Township Rampe Secyon <br /> TO BE PERFOR ED: <br /> WELL!BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER? <br /> O,SOIL BORING# ? <br /> DESTRUCTION(choose type below) <br /> . <br /> 0 WELL# a OVERBORE <br /> JA ENTS: <br /> GtvutSpecifl cation s•. 0 PRESSURE GROUT <br /> 'E p WELL )NSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> I�nrmNG HOLLOW STEM DIA OF BOREHOLE S!n MULTIPLE CASINGS?BYES NO WELL CASING DIA <br /> APOR`-t•�,�n'N OAIR HAMMERIDRNEN CASING THICKNESS TIDE OF CASING: OSTEEL nPvc 0OTHER; <br /> APOR I1 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: II AUGERS n HOSE <br /> XPARGE0 PUSH POINT GROUT SEAL PUMPED: 0 Ycs p No [NOTE: MAXIMUM FREE-FALL DEPTH IS 301 <br /> BORING Q HAND AUGER GROUT SPECIFICATIONS: <br /> FR0 n arHEFL__ APPROX.BORING DEPTH SO'- ,,( 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? I If YES.Est specifications here)` <br /> �PJ9Ts: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS.CALL THE UNIT N INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Ireby certify that I have prepared this application and that the work will be done in accordance With San Joaquin <br /> t:-y 1OrA�I1lrn�'dinan(,cce//e1s, Rules and Regulations,and all applicable California <br /> State Laws. <br /> �"^-1�-t �--orf 0 r TldeICompetryttleJ" <br /> me G}�-�-= Q�®n.. t D2tB 9'.r r7•D1_ �• <br /> DEPARTMENT USE ONLY <br /> 'E MAP IN UNIT N FILE,ADD SS; <br /> >�PLAN DATED: 4�j OJi `rS�A <br /> 18bOn Accepted By JJate Issued�12-3t6L pre ,9S <br /> spaetian 8y Dai Fnol Inspection By Date <br /> an Inspection By _ Date <br /> IMENTS I CONDITIONS: <br /> UNTING ONLY: AID# <br /> ❑ore <br /> CODES FEEINFO AMOUNTREMrRED CHECK# RECD DY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> I WC .WAI Pl C-57 Letter of Allthorimtion to sign permif�-- Encroachment dos 1/25/02 <br />