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_ id 1894683433 FIFTH FLOOR <br /> PAGE 62 <br /> ,n Joaquin County <br /> AgoEnvironmental Health Department <br /> 344 East Weber Avenue,3rd F]Oar, Stockton, CA 95242 MITIGATION <br /> (209)468-3449 Fax (209)465-3433 Web www sigov orglehd UNIT IV <br /> RON-REFUNDABLE PERMIT IXPIRES 1 YEAR FROM DATIr ISSUED JU <br /> �`, <br /> �ppljcadon is hereby made to San 3oaquln County for a permit to construct andlor rnstaiR the work dFscnbed , Is�appli U9 TH�¢n Compl< ce vnth <br /> ent <br /> loaqurn County t)evelopmsnt TiIIe,Chapter 9-1115 3 and the Standards of San loaqurn County Envrronmen PER <br /> ,PAI <br /> 5 cvnA � b 1vt� cross Street l o �I'd city `[� <br />�fELL Location <br /> GROPETY ,t � o�Dq>t 1V C ty u ILK ZJ070SC Phone# <br />'wrier !l� tW Y 5 G Add ress <br /> C-67 Conb-actor ' l Addrnssyp h+� Grry AY'ti net T7p 5511rdt 85 Phone#C10 it" KY-313-5'360 <br /> Consultant f St7b-Cnt1 LA1+Nbri�1 Address -? kl s City San g Ltae Phone# D 3f��`g <br /> GIS Coordinates X —� <br /> �r Township Range Secbon <br /> WORK TO E PERFO MEI]' <br /> NEW WELL 1 BORING {GPT,G£OPROBE,Nl'DROPUNGH,HAND AUGER OTHER-) VESTRUCT'ON <br /> OVER BOREDIAMETER DGe1ow)— <br /> l]SOIL BORING# PRESSURE GROUT <br /> j)WELL* <br /> GROUT SPECIFICATIONS <br /> 13'Other �.t„p r <br />�OMMENTS LC i E�t-1' l�an, fyQ r U �t 1�L <br /> TYPE OF VELL INSTALLATION TYPE CONSTRUCTIO SPECIE CATIONS �r <br /> MONITORING OLLOW STEM DIA.OF BOREHOLE_tp, a MULTIPLE CASINGS []MULTI-LEVEL WELL CASING DIA._�._,-__ <br /> p EXTRACTIpN ]]AIR F(AMMER/DRIVEN CASING THICKNESS Sin i 0 TYPE OF CASING d STEEL XPVC Q OTHER <br /> wOR n MUD ROTARY DEPTH OF GROUT SEAL <br /> TREMIE TYPE TO BE USED nAUGERS a HOSE <br /> PARGEI OZONE n PUSH POINT(GP or Ct'T)GROOT SEAL PUMPED p Yea {]No (NOTE_MAXIMUM FREE-FALL DEPTHIS 30') <br /> Q SOIL BORING HAND AUGER GROUT SPECIFICATIONS <br /> i]OTHER OTHER APPROX BONING DEPTH � � 13 BOLTED TRAFFIC BOX or I]STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (rf YES list specrficatons In comment secban) <br /> COMMENTS <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS_ <br /> I hereby certify that I have prepared thlS application and that the work will be done in accordance with San Joaquin <br /> County Ordtn Fr gulations, and all applicable California State Laws, <br /> rI / <br /> �raScJCompany <br /> Signed x O <br /> t�3tB <br /> Print Name <br /> DEPARTMENT USE ONLY�! 8 <br /> SITE MAP IN UNIT IV FILE,ADDRESS' � C�G '� <br /> WORK PLAN DATED' 01 <br /> Date tssued ti+ (, —0 Area <br /> Application AmePted BY bats <br /> Grout Inspection By Date trial Inspection By <br /> DestrucWri Inspection By Date <br /> COMMENTS/CONDITIONS <br /> COUNTING ONLY AID# FAC# <br /> CODES FEE INFO AMOUNT REMITTED CHECK# RECD 6Y DATE PERMITI SEi'cr REQUESTS INYDICE <br /> 358 � �.� l� <br /> C-57 WC -WAIVER C-57 Letter of Authorization to Sign perm+ Encroachment doc <br /> EIID 24-02-001 <br /> onnnoM <br />