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WEL . IERMIT APPLICATION . %1M SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY UNIT IV <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95242 <br /> (269) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> \pplication is hereby made to San Joaquin County for a permit to construct andlor,install the work described. This application is mace in comptiance with San <br /> 'caquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department, <br /> VELL Location 2-565JS� Crass Street bviCCty �{� i 15 Assessor's <br /> (AV � <br /> Parcel# 2�7$ -OZO '()4 <br /> 'ROPERTY Owner ,CP .-&D`u kQ Zr Address A.0.164 QI� City •I Zip q53 76 Phone# Df -059 <br /> i <br /> -57 Contractor 4e-(I Df- kivt Address kwl n, la2-Wll=ttxp�{11 CityQ*'-Cko�•a'a Zip j5b7l)Lic#� Phcne# 1q U-35 <br /> :onsuitant I Sub CntrtY 5 e C R1 Address_.. e� City SI u1-� Lic#_i;20�2 1 Phone# _qk I —100& <br /> ;IS Coordinates:X Y Township Range Section <br /> IORK TO RE PERFORMED: <br /> i NEW BORING(CPT, GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER") L' DESTRUCTION (choose type below) <br /> Q SOIL BORING# { 11 OVER-BORE <br /> RWELL# J �, [I PRESSURE GROUT <br /> Dther: Grout Spea cations: <br /> :OMMENTS <br /> YPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING Z 1OLLOW STEM DIA.OF SCREHOLE_ 'i MULTIPLE CASINGS?©MUL T€-LEVEL? fg WELL CASING CIA: <br /> EXTRACTION [1 AIR HAMMER/DRIVEN CASING THICKNESS 5�.SIO TYPE OF CASING: 11 STEEL, 'PVC I]OTHER: <br /> VAPOR D MUD ROTARY DEPTH OF GROUT SEAL.ZZT TREMIE TYPE TO BE USED: XAUGERS 0 HOST i <br /> AIR SPARGE/Ozone D PUSH POINT GROUT Sim PUMPED: Zyes [I N+o+ (NOT '} <br /> E: MAXIMUM FREE-FALL DEPTH IS 30 <br /> SOIL BORING a HAND AUGER GROUT SPECIFICATIONS pn f rift <br /> OTHER: t7 OTHER APPROX.BORING DEPTH Z. yy, BOLTED TRAFFIC BOX or O STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> :OMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 46 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> :ounty Ordinances, Rules and Regulations, and all applicable California State Laws. ! <br /> p� <br /> igned z ,[1�}1�Al I Jam � TiflelCompany � <br /> Tint Name <br /> haart PT _ Date tr t <br /> t1 P I-iS�M1 <br /> DEPARTMENT USE ONLY <br /> ;ITE MAP IN UNIT IV FILE, ADDRESS: <br /> YORK PLAN DATED: <br /> ppiication Accepted By ! Date Issued^ //{�J���.�T Area <br /> ;rout Inspection By Date Final Inspection By Date <br /> ') <br /> testauction inspection By Date�r <br /> :OMM£NTS/CONDITIONS: C� ' C. 41 '[ x t <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC-D BY DATY PERMIT/SERVICE REQUEST# INVOICE <br /> :-57 WC -WAIVER C-57 Letter of Autho"atio o sign permit Encroachment dor $/Z9/q2 <br />