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�Hru3RIA <br /> eau ave u><u �, <br /> y ULlA6� 1707 935 6649 P,02x02 <br /> En onmerptaY Health De <br /> "" .' 30Y East WeberAv artinen• <br /> (209)468-3449 F IO017, Stockton, CA 95202 SITE <br /> o ax: {209)468-343 Web; �v.sjgov.org/ehd <br /> NON- MITIGATION <br /> REFUNDABLE PERMIT CXPIRES 7 Y UNtT Iv <br /> JoaquinhCo ther l�oade to San Joaquin Coun <br /> EAR PROM DATE ISSUED <br /> Pment Title,Chapter 9-t b for a d the <br /> 1 to eonstni <br /> 715.3 and the stand/or install tho <br /> WELL Lo Standards of San J Work described This <br /> P ,alien yp (� f �y �� oaquin Caunry Envi.onmenLa!Heb Dena emade in compliance <br /> `�^�✓7Yr 1 / vri+n <br /> PROPERTY ""'�y" Cross Street L5id 72 <br /> Owra 5..4 �,1� 'ry a/df .. Assessors <br /> C-57 11 ddb's-u. 1 �p—�--�ParcctY 5-d30-, <br /> s sY"V <br /> n7aaor Gr �� <br /> 06- `' Add ess y '��City T � — ,2;y 9'50% <br /> Cons Wtam . Phone* <br /> q. q <br /> GIS CcdrdFnates;� �'----Addy, z p ,/� �,"-"'�p"�- i�+4��Phon <br /> Y s felly e�t4zt <br /> WORK TD 6E PERFORMED: -- Township L ------__Phoney o <br /> NEW WELL ORIN cpr,GEOPRoe= — --Range <br /> 27_F <br /> SOIL SORIN --- Sectian------- <br /> --L <br /> --- <br /> ❑ri'ELL* G* �� "p��ROPUNCH,HAND-AUGER,OTryER• <br /> COMMENTS mer ' 13 Q D R DESTRUCTION <br /> (choose typo below) <br /> Q PRESSURE GROUT <br /> ETERS_ <br /> TGROUT'SPECIFICATIONS <br /> TYPE O � iN5 <br /> Q MONITORING I W ST M''E CONSTRUCT, S""-- P—�l..rT10NS <br /> Q EXTRACTION HOLLOW STEM <br /> Q AIR I'IAMMER1pRiVEN DIA,OF BOREHOLE ' <br /> Q VAPOR CASING THICK)gE�' A MULTIPLECASINGS Ij MULTI.L;�,EL yp <br /> p AIR SPARGE,OZONE UD R07AIZy DEPTH OF EAN'�—�TYPE OF �L OASING DIA:_ <br /> USH POINT(GP or CPT)GROUT GROUTS PUMPED:UO 'SING. Q STEEL Q PVC p }il.-RR,, <br /> �w`OIL BORING Q HANG AUGERTREMIE TYPE TO BE USED; g'A 1 d. "` -- <br /> lkyes p No ( OTE: MAClMUM FR1=E-F <br /> QOTHER:__` 17 OTHER GRDUTSPECIFICATfDNS ./� ALL DEPTH S got <br /> COMMENTS: ` CONDUCTOR QASINN PROPOSED / n <br /> p BOLTED TRAFFIC OX w <br /> IN YES*rr„t spnni5ra@onv In)ecmmeE PIPE <br /> NATE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PE <br /> 48 rpd thiNG HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that I have PERMITS. <br /> County Ordinances, RUlaS sand Reg this apPGcaGQn and that the work W 71 <br /> gUfatlons, and all applicable California State Laws, / 'with San Joaquin <br /> Pnnt Name I TjIIeluompany „, SIL` <br /> DEPARTMENT USE ONLY Dale 17- <br /> SITE <br /> SITE MAP IN UNIT 1V FILE, DR SS: Ur4� <br /> WORK PLAN DATED: a� 6 <br />=mut Inspecdon 9y'f �-. <br />'s"S"Oton! — ^ Uate Data Issued 3U O <br /> r+specNon By _ Inal Inspection ay <br /> OMMENTSJ CONDITIONS: Data Oats 2 0 <br /> 4CCDUNTING ONLY: AID# - <br /> E CODES FEE INFO AMOUNT RE FAO# <br /> 7 MITTEO CHECK* REC'D BY DATE <br /> 1933 PERMIT/SERVICE REQUEST* INVOICE <br /> 57, Wc..—WAIVERv II b SR# ��O O <br /> DZ9-r>z,gol C <br /> S <br /> — — y Letter of Author izotion to sign <br />>/7005 permit_Encroochment doe <br /> TOTAL P.02 <br />