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-..!,, WE PERMIT APPLI ATION h SRM SrIT <br /> M-nRECOVERN JOAQUIN COUNTY PUBLi. HEALTH SERVICES UNIT I <br /> JAN 3 2002 V TION <br /> ENVIRONMENTAL HEALTH IVISION (PHS-EHD) UNIT N <br /> - <br /> 304 E. Weber, Third Floor, S ackton, CA., 95202 <br /> ENVIRONMENT HEALTH (209) 468-3 <br /> PERMIT/SERVICES <br /> 209) 468- <br /> PERMITISERVICES <br /> BION-REFUNDABLE PERMI EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County tar a permit to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin County Development Tide,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environment SDivision. <br /> WEI LLnr2tion atD �. vt'Q- Cross Street !' M city + an Q ap �553(0 Pard#_��-I-oy�Vog <br /> PROPEK17 Ownerli C�l Address D61 .0 L-1—/1 G �p°K33"� •Phone# � -X3aC <br /> ;rt Address City AO Zip�c Ucj ��96 Pttianef 0T) 31�� <br /> C-57 Contractor <br /> Consultant/sub Contractor Address _7 P CityyLic �Phcne# -62 -- <br /> GtS Coordinates:X ,Y Township Range Sec_ion <br /> WORK TO SE PERFORMED: DESTRUCTION(choose type below) <br /> EW WELL/BORING(EP-r.GEOPROHE,t-IYDROPUNGlf=HANt)-AUGER,OTtf ) Q OVER-BORE <br /> .BOIL BORING# PRESSURE GROUT <br /> j]WELL# <br /> Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFIC TIONS <br /> 0 MONITORING j]HOLLOW STEM DIA.OF BOREHOLE '' MULTIPLE CASINGS?I]YES [I IVa WS CASING Ow4a <br /> a EXI•RACTION EI AIR HAMMER/DRIVEN CASING THICKNESS S TYPE OF CASING: ]]STEEL I]PVC 0 OTHER <br /> (]VAPOR [I MUD ROTARY DEPTH OF GROUT SEAL L 1+�r TREMIE TYPE TO SE USED: GAUGERS {OSE <br /> []AIR SPARGE )116 1 LlSH POINT GROUT SEAL PUMPED: es Q No (NOTE: MAXIMUMe F� <br /> VSR_EE-PALL DEPTH IS 30') <br /> OIL BORING ]]HAND AUGER GROUT SPECIFICATIONS: �^ <br /> r BOLTED TRAF`riC 80X ar {]STOVEPIPE <br /> ]]OTHER �]OTHEi t APPROX.BORING DEPTH 0 <br /> CONDUCTOR CASING P.RC POSED? (if YES,list specifications here): <br /> "COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCE.SSOR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS Ih ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> I hereby certify that I have prepared this application and that th work Will be done in accordance with San in <br /> County Ordinances, Rules and F3pgjulatlons, and all applicable alifamia State Laws. <br /> Signed x <br /> -Title/0)mpany C? <br /> Print Name <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: o'� 1 C7 tn1 e}�►'�D "` �` '�cam` <br /> WORK PLAN DATED' <br /> Application Accepted Sy Date Issued <br /> Grout Inspection By_ e�C^^^^�L� <br /> Date l D Z Final Inspection By Date b <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONDITIONS' <br /> ACCOUNTING ONLY: AID# <br /> PE cOOES FEE INFO AMOUNT tZEME?7ED CHECK# REC`U BY DATE PFRMrr 1 SERVICE REQUEST# kI(YOIG1r <br /> -per I bo l fio s <br /> C-57 WC -WAIVER C-57.Letter ofAuthorization to sign permit-,--Encroachment doc 9/27100 <br />