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PERMIT APPLICATION F M SITE <br /> R; r'_ ; •I � SAN JOAQUIN COUNTY TION <br /> IV OF <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT MITIGAAAPR 28 P11 43 , Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 FILE Y <br /> NON-REFUNDA13LE PERMIT EXPIRES 9 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to Construct and/or install the worn described. This application is made in compliance with <br /> San Joaquin County Develo71npment T`al Chapter 9.1115.3 and the Sta ards of San Joaquin County Environmental Health Department. <br /> Assessors /V576 zoo <br /> LL Q <br /> WELocation C Cross Street 4 City <br /> Parcel# l <br /> PROPERTY�J��f �� � 3 � '( ?c/ <br /> Owner 1`I[ i A_ dd2ss• Cit , aPhon. p <br /> C-57 Contractor U QIlUQ� Address D Cay fdYl C zip Lic4t1 PhQne#_D <br /> Consultant/Sub Cntr KIe I g, Address Z�z� �. r1{Tre City Lic# Phone' 7 <br /> GIS Coordinates:X Y Township Range <br /> Sectlon <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING (CP HYDROPUNCH,HAND-AUGER,OTHER') >) DESTRUCTION OVER-GORE. (choose type below) <br /> o SOIL BORING# <br /> DIAMETER <br /> �WELL a PRESSURE GROUT <br /> GROUT <br /> Q`Other ��Or�` SuRG �1C'R' I <br /> SPECIFICATIONS i� L6lhA`J SVCS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING []HOLLOW STEM DIA,OF BOREHOLE a MULTIPLE CASINGS 0 MULTI;LEVEL WELL CASING DIA. <br /> Q EXTRACTION AIR HAMMER/DRIVEN• 'CASING THICKNESS TYPE OF CASING U$TEEL• .Q PVC 0 OTHER: <br /> a VAPOR 0 UD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: Q AUGERS p He <br /> p AIR SPARGE/OZONE PUSH POINT(GP or GPT) GROUT SEAL PUMPED: p Yes U No <br /> OTE: MAXIMUM E-FALL DEPTH IS 30') 5tU[[^`I <br /> SOIL B RIN Q HAND AUGER GROUT SPECIFICATIONS _ t(', <br /> OTHER: 0, OTHER APPROX.BORING DEPTH 0 BOLTE i!C BOX or Q STOVE PIPE <br /> CONDUCTOR CASING PROPOSED IijA-' (if YES.list specifications in comment <br /> I hereby cji <br /> that I ave repared this application and that the work will be done in accordance wi h San Joaquin <br /> County Oce ule ndRegulations,and all applicable Califo a State Laws. <br /> kle(6 F <br /> Tdie/Company 1 4rSigned x <br /> Print Name 1 Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted B Date Issued Area v�2 <br /> PP P Y — <br /> Grout Inspection By Date Final Inspection By _ Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D 9Y DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 21D SR © 3 <br /> C-57 V WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 9/30/02 <br />