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C3;32 2C@4 11 15 2034x383433 FIFTH F!OIDR PA(3E a2 <br /> San Joaquin County <br /> Environmental Health Department S ITE <br /> f 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> (209)468-3449 FLe (20) 468-3433 Web w-%-,Ar co san-Joaquin Taus/eked UNIT IV <br /> NON4ErUNDASLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Appiicati❑n,s hereby made to San Joaquin County far a permit to canstrctct andlvr install the work descnhed Thi;appllcat�on Is made m compliand�with San <br /> ' Joaquin County Deveicpment Title Chapter 9-1115 3 acid the Standards of Sart Joaquin County Envunnmental Health Oeparlment <br /> l, AssB6Sa5 <br /> WELL.Location l'�l f�� '..-1 Mt uass Slraet City C Z:p l- Parceik <br /> PROPERTY { b� l 0 0,^ r' S L<1L/Lq t� Q `�[��� 3 Y <br /> Owner Address s a qty rr p 4 (ac Phone�#��t� <br /> C 37 Contractor r n l' c Address 9 Q d{a.rv_ d Gab/ Jori n2 Zlp �l�c#'` � <br /> Consultant f Sub Cntr �n � t Address y 9s`rPsr'rrt r �,rr�,S' Gary � � ic# Phone#(7,17) p{O <br /> GIS CaordinatgS X j a N 37 75'-15_ Y Cees WIds,( q3 09 Tewnsh,p Range Section o2 <br /> WORK TO BE PERFORMED <br /> NEW WELL BORING (CPT GEOPROBE HYDROPUNCH HAND-AUGER OTHER-) (3 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE DIAMETER <br /> K'WWELL# �_ o p t 0 PRESSURE GROUT <br /> 0 Other GROUT SPECIFICATIONS <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS if <br /> ' `ICNITORING HOLLOW STEM DIA OF BOREHOLE !)MULTIPLE CASINGS 0 MU4TI-LEVEL WELL CASING DIA ^ <br /> 0 EXTRACTION p AIR HAMMER(CIRIVEN CASING THICKNESS TYPE OF CASING p STEEL, PVC 0 OTHER <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL_xy TREMIE TYPE TO BE USED *`UGERS a HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CRT)GROUT SEAL PUMPED U Yes �lo (NOTE MAXIMUM FREE-I-ALL DEPTH IS 36') <br /> USOIL BORING 0HAND AUGER GROUT SPECIFICATIONS_C?_vvRetr� -e ' /e 6 0-6 14+.<w-- F 2''d-,,, <br /> 0 OTHER 0 OTHER APPROX BORING DEPTH�;n——5 c3� 0 BOLTED TRAFFiG E!CX ar 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED, O o . (if YES slat specficavons In comment sectlon) <br /> ' COMMENTS <br /> NOTE OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 1 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby certify that I have prepared this appilcatton and that the work will be done in accordance with San Joaquin <br /> County Ordi es d �e�,�Zl,.,ns, and all applicable California Stale Laws <br /> Signed c � TitlelCompany <br /> u Date– <br /> DEPARTMENT <br /> ateP <br /> 1 Pnnt Neme _DEPARTMENT USE ONLY nj�C� <br /> SITE MAP IN UNIT ISI FILE,ADDRESS 1-5 [n1L 1 <br /> WORK PLAN GATED MAR 2 -5 204 <br /> APPlicabon Accepted By Dste Issued <br /> Grout inspection By Date Final 4nspectg3n By Winn el r r�i € <br /> ' Dettruc'ion Inspealon By Date <br /> COMMENTSI CONDITIONS <br /> ACCOUNTING 7—T! <br /> AIDit �ACtt <br /> PE CODES FEFINFOAMOUNT REMITTED CHECK+`� R£C D SY DATE PERMIT f SERVICE REQUEST# INVOICE <br /> 5� � Ioa�fS [ sR# 3?,3 9 <br /> ' C-57— WCT WAIVER-- C-57 Letter of Authorization to sign perMit_Encroachment decT <br /> EfID 29 02-OC I <br /> 9'3(7'200? <br />