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tr.J! uf/ LVVV iVL� LV�4VVv1.,.... r rL <br /> - M , <br /> San Joaquin County ---- ---'�"T <br /> SITE <br /> r' ay Environmental Health Department ?JIITIGATIC)N <br /> �• 304 East Weber Avenue,3rd Floor,Stockton,CA 95202 UNIT IV <br /> (209)468-3449 Fax. (209)4•68.3433 Web:w�w:co.san•�as�uin.cfl.us/ehd <br /> — <br /> �`rF—O NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> caion I--hereby made to 5<n Joaquin County foe a permit to construct andfor Install the work described, Thls apoicalion is made in compltance wi;h San <br /> J:):;quln County Development Title,Chapter 9-1115-3 and file Stanels da of San Joaquin County EnAdanmenlal Health DeFadjnent. <br /> Aastsssor: <br /> CiyrSlac�—zip--------Percel�k/L8,r/9�..=�-•� <br /> _�_E_Locatlon , —Cross Street�_ <br /> pF;OPERTY �,7�7 <br /> PhonEd 8Z-t yb <br /> r:ner eta r AA ddress� Al,.)1 -'�Clty STnc�� -- <br /> N'2��i�,�tP o Z'P ?7Z1 Uc;►52 c2WSI Phonal LCL <br /> a;<S7 CGntraclor T�,eT a��aT�:s Address <br /> Consultant!Sub Ont T�Ie t� j <br /> Address_?_T27 F City�G€ _Etc <br /> Ssctlon 24, <br /> G:3 Coordinates:X <br /> Y---''rownship /m. RangeJL — <br /> JgnRK TO BE P8 FOR ED: <br /> NEW WELL/BORING (CPT,GEOPROBF-,HYDROPVNCH,NAND-AUGER,OTHER") pODOEER BORE ld IAM(choose_�pe� b�t�N <br /> SOIL BORING P_( , .L�; -�= 3 � p PRESSURE GR�DIJT <br /> 0 WELL yk GROUT SPECIFICATIONS_�_ <br /> a*Other <br /> aW.7NIMENTS: <br /> TYPE OF WEL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> r,10NITORING HOLLOW STEM pIA.OF i30RENOLE— 0 MULTIPLE CASINGS D MULTI•Lev8L WELL CASING DIA: <br /> _TYPE OF CASING: []STEEL. Q PVC Q OTHER; <br /> :7 FaTRACTtON 0 AIR HAMMER/DRIVEN CASING THICKNESS 7REMIE TYPE TO SE USED: O AUGERS D NOSE <br /> ,,,.POR G htU:)ROTARY DEPTH OF GROUT SEAL <br /> rl2 SPARGE/OZONE 'p PUSH POINT(GP or CPT) SEAL PUMPED: 0 yes p No <br /> r -(N OTE:MAXIMUM FREIz-FALL DEPTH IS 30') <br /> f(5�•ILSORING s7HANDAUGER GROUTSPECIFICATiONS <br /> i BORING a OTHD AUGSR APPROX.BORING DEPTH p BOLTED-TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED _(if PIIS,list specijcatlons in comment V26on) <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHIVIENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS, <br /> I hereby certify t t I a prepared this application and that the work will be done in accordanc®with San Joaquin <br /> County a s (R 1 egulations,and all applicable California State Laws. <br /> 7itltJCompany G <br /> .ign3]x f�/ZwG��n <br /> ��Datc �_ / G <br /> -r!r:t Name <br /> DEPARTMENT USE ONLY <br /> ;>ITE MAP IN UNIT IV FILE,ADDRESS: <br /> bVORK PLAN DATED: Z0 ZDOCo — <br /> Date lscus�° 6 � 2- <br /> Accepted <br /> „__ Arod�.�---• <br /> poli adonAcceptedBy �1 <br /> 3; ut inspection By _ data 0� Final Inspection ay ---•--- �M� <br /> Destructian inspection 6y Date .� <br /> COMMENTS/CONDITIONS: SA <br /> ACCOUNTING ONLY. I AID* F <br /> PE CODES FEE INFO AMOUNT RSM1TTEi? 7CK!1 RECDSY DATE PERMITI SIik4VICP_p)=QU69T# IIVVrJtC E <br /> �.0 8c- i8�� ev�3 (JIB– 7z X, s d <br /> C-.57_ WCT WATVER,_ C-67 Letter of Authorization to Sign permit Encroachmen-r doer,., <br /> ShHDY,y29-02-001 <br /> YI.sO(,iVOL • <br />