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EL PERMIT APPLICATION -YRM SITE. <br /> M171ATiON <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH D VISION (PHS-EHD {� ' <br /> � <br /> 304 E. Weber, Third Floor; Stockton, CA,, 9520 <br /> (2a9) 468-3 JAN 2 2 2002 s <br /> NONA0=UNDARLE pr=RMrr EKPIRES 1 YEAR FROM DATE l58l1EP U"96 4- <br /> wilb San <br /> Application is hereby made to San Joaquin County for a permit to construct andlar install the work dela ihed. This apR�Wyrs <br /> Joaquin County Development Tilde,Chapter}t-1'15.3 and the Standards of San Joa County Public Hesith Services, a p21 C�ivisian. <br /> LaCs Street i 1 City <br /> G Zap (6 ?arca[# -h�A -sy <br /> WE.I. �tticn � <br /> • ros _ <br /> L b !I/1ca>7CG� Address Gty vn� Z1p <br /> PROPER Y OwnerT IIryG�aaij�ip`�'S1-lic7.Phon <br /> C-57 Contractor Address . � C+tY — <br /> - ) <br /> Gonsui4pt!Sub Cont-actor var; �C�GI 6b� Address Sa.� <br /> GIS Coordlnates:X Y <br /> Township Range Section_ <br /> W {TO BE i FaRIVIEi]: Q DESYi RUCTION(&Qose type below) <br /> NeM WELL/BORING(CPT,GECPROBE.HYDF2aPUTfG i.HAND-AUGER,OTH R"} Q OVER-BORE <br /> Q SOIL BORING# Q PRESSURE GROUT <br /> '' <br /> tN ELL# Z"' S —Grout per8c3tion <br /> r: s <br /> *Othe <br /> COMMENTS: <br /> iN ALLATION TYPE CONSTRUCTION SPECIFaC TIONS 'r <br /> TYPE OF wELL ,. O WQ1 CASING DIA: <br /> DIA.OF BOREHOLE r 1` MULTIPi�CASINGS?U YES <br /> MONITORING GLLOW STE3A C 11 CT {ER: <br /> [)EXTRACTION Q AIR f-IAMMF�fDRIVEN CASING THICKNE55 TYPE OF CASING: Q 5�=;- <br /> 0 VAPOR Q MUD ROTARY oEP TH OF GROUT SEAL z TRE?AIE TYPE TO BE LfSIw�7: UGERS Q HOSc <br /> AIR SPARGE {]PUSH POINT GROUT SEAL.PUMPED: II es �lo (NOTE: MAXIMUM FREE-FALL DEQ IS 30°} <br /> SOIL BORING 1]HAND AUGER GROUT SPECIFICATIONS. OLTED TRAF^IC BOX ar Q STOVI=PTFE <br /> IJ OTHER OTHER APPROX.SCRING DEPTH <br /> CONDUCTOR CASING PRC POSE-0?A&2 (ifyFS,list specifications hese)- <br /> *COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACC �wc�NoACHMENT oR PERMITS. <br /> EOU RED INS OTnS• <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOUR <br /> I hereby certify that I have prepared this application and that thework will be Laws,one in accordance With SaA.,-44 n <br /> County Ordinances, Rules and,Zegulatiens, and all applicable Irforn � <br /> �-�-v ;s <br /> Tilte! mpany , <br /> Signed X <br /> llh�l liLi" DahE; <br /> Print Name DEP ME SE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: u t <br /> Date Issued 2 D Area <br /> Application Accepted BY Date ! 7-46rrirtal Inspection B Date <br /> Grout Inspection BY <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS. <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE lNFB AMOLI!!T REPAI.MiD CHECK# RIEC' BY DATE <br /> PERMrT!SERVlGt=Ri`{tt1EST# }NVQICS <br /> �.G:s 3 <br /> C-5/ WC -WAIVER C-57.Letter of Authorization to sign permit Encroachment doc <br />