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r R JA�I-A L <br /> 1 oIAIELL WRMIT APPLICATION FO SATE <br /> SEP SAN JOAQUIN COUNTY {� U �IV <br /> 0 2003 ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> ENVIRONMENT 304 E. Weber, Third Floor, Stockton, CA,; 9''5202 <br /> PERMIT'ISERVICESTri (209) 4G8-3449 '� <br /> I NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> .pplication is hereby made to Sari Joaquin County for a permit to construct and/or install the work described.IThis application is made in compliance with San <br /> Paquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department <br /> /ELL Location 1250 N. W;I son WA, cross Street arkn City SiaK+0,% 7.ip 95.20 2 Pa�rce so rYZ 3/y of <br /> 'ROPERTY Owner��r d, I C U. -Address 131 J(p Tftgff,-,4j City 5aA�4 AFP- Zip j{)(c,7D Phone#92 <br />' :_57 ContradoSNS�Tv 4adress SD auf� _City1!�1tx1 ys jsljc#-461-1bf;Phone#_g2.5 3136ft . <br /> �r <br /> :onsuitant/Sub Cntr Address $37 S1naW Zk City ic#6 7 Phone# 'ylo7100(o <br /> ^ II <br /> 'IS Coordinates:X 3?. ��ra -�oZ y Z� Y21--�S 0S3 ,Township Range Section <br /> t ;i <br /> 'JORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROP_UN HAND- U EP OTHER-) p DESTRUCTION(choose type below) 1 <br /> X501L BORING#C P 1 C� € OVER-BORE <br /> O S ` WELL# 0 PRESSURE GROUT <br /> Other: � e. Grout Specifications: <br /> :OMMENTS it <br /> YPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> (MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?0 MULTI-LEVEL?0 WELL CASING DIA: <br /> - <br /> j EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS - bA TYPE OF CASING: []STEEL [I PVC 0 OTHER: <br /> I VAPOR p MUD ROTARY DEPTH OF GROUT SEAL j D TREMIE�TYPE TO BE USED: []AUGERS ;R HOSE <br /> I AIR SPARGE 1 Ozone XPUSH POINT GROUT SEAL PUMPED: j.Yes p No (N "MAXIMUM MAXIMUI�M FREE-FALL DEPTH IS 30') <br /> ]SOIL BORING. aHAND AUGER GROUT SPECIFICATIONS: TD To S{urEc�Ce. <br /> I OTHER: p OTHER APPROX.BORING DEPTH IW-1 1} 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> F <br /> CONDUCTOR CASING PROPOSED? f if YES,list specifications here): <br /> COMMENTS:, JOt 1 ,b�ir1!�& (a ] ipOCi-!�JS- P �4Ca��'4r1 I Q1 C-L i <br /> n S Afov^ r <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> hereby certify that 1 have prepared this application and that the work will #;e done in accordance with San Joaquin <br /> ;ounty Or s, Rules a Regulations, and all applicable California State Laws. <br /> �c I <br /> ;ignedx Title/Company CRJ - or A�i.Gn s� Geo r: iC r,e.�4a( <br /> E <br /> et -- Date teM 1 <br /> ?tint Na # <br /> DEPARTMENT USE ONLY. <br /> SITE MAP IN UNIT IV FILE,ADDRESS'. , ��`�v N• !�l/[���/'t u/ <br /> WORK PLAN DATED: b3 t <br /> � <br /> •SPP <br /> lication Accepted By Date Issued `�! .� Area{4 <br /> Grout Inspection By Date Final Inspection By. �► ate <br /> Destruction Inspection By Date <br /> II I� <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE j PERMIT/SERVICE REQUEST# INVOICE <br /> 3sn I _S13 E !ao 470 9-16 tj 4D35.512- r <br /> C-57 WC WAIVER C-57 Letter of Authorization to sign permit Encroachment dop it <br /> E rap y <br />