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66/22/2664 14 29 2094683433 FIFTH FLOOR rAlat UZ <br /> .TUN-22-2604 15 11 CAi11BRIA P-02/05 <br /> uAIL avi2quaill a.,UUlttty <br /> Environmental Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor, Stocldon,CA 95202 MITIGATION <br /> (209)468-3449 Fax (209)468-3433 Web-www Sjgtn.ourglehd UNIT IV <br /> • NON-REFUNDABLE PERIMIr ExPIREs 1 YEAR FROM DATE ISSUE <br /> AypbcaC+on is hereby made to San Joaquin County for a permit to contract andror,ristall the weric descdbed Ttus apphcaboh is made in compliance with Szr <br /> .loaqurn County DevefapmeM rile,Chapter 9-11IS.3 and the Standards of San Joaquin County Environmental Health Departmonl <br /> Assessors <br /> WELL LAaatlon�� GcSit , # ` - <br /> PROPERTY <br /> avn,r3rst+{g tAt Pf,QrM4 %:U5 Address"4 _} � •r.r.,{cu f1 c-ty CaZIpCiCSIL)Phone7l <br /> C-47Contr3ctor Dj►At a Adaress55ti aty �z1� S53LSt Phone#Qz1 <br /> Consultant I Sub Cnl1',Ckeiiab;� %g ee .%0V4Ar4ddrWsjZ D #:rit City L"A-^ Uc# Phonea-1'O S3-11 1 <br /> GIS Coordm*ev X Y Township Range Secllon <br /> WORKT'O_BQ_PERFO&IM i? <br /> a NEW WELL l 13ORING (CPT.GEOPROW HYDROPUNCH,HANGS-AUGER OTHER') D DESTRUCTION (oAoase type below) <br /> [I SOIL BORING# Il OVER-BORE DIAMETER <br /> []WELL# JWRESSURE GROUT -W1 Lk �� <br /> 13*Other GROUT SPECIFICATIONS QVej - <br /> COMMENTS G VVV-t Wdk, &tCC tileC4Vri r-kctai.lei S o , IxS i g <br /> a <br /> HYPE OF WELL. IN STA TI E CONSTRUCTION SPI~CJf1CA]Z�f{,S <br /> [I MONITORING ]]HOLLOW STEM DIA OF BOREHOLE []MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA <br /> p EXTRACTION 11 AIR HAMMEFUDRIVEN CASING THICKNESS TYPE OF CASING d STEEL 0 PVC D OrHER <br /> VAPOR g MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO DE USED []AUGERS 12 HOSE <br /> ITSPARGE!OZONE 1]PUSH POINT{GP or Ct�GROUTS EAL PUMPED [IYes []NO (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> OIL BORING ;]HAND AUGER GROUT SPECIFICATIONS <br /> 0THER OTHER APPROX BORING DEPTH U BOLTED TRAFFIC BOX or U STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (of YES.hat spealiicatioriis in comment section} <br /> COMMENTS <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCRVACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County es R 1 s and Regulations,and nd all applicable California State Laws.}^ l <br /> $rgnedx LL T-WelCornpan �&ittb1,; ; Gt'IIrl p'(�3jiY>!L'Yi��•,i�.,r/e 91OfG �( <br /> Pnnt Name h�•� <br /> pEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED.' / <br /> Application Accepted By tL��I � Date Issued Area <br /> Grout Inspection By Date Final Inspection By Dam <br /> Dssmucbon Inzet-tlen 13y Date <br /> COMMENTS f CONDITIONS. <br /> Accour4TfNG ONLY A{D31 FACit <br /> PE CODES EEE INFO AMOUNT REIMITTED CHECK# REC'D BY DATE PERMIT SERVICE REOUEST# INVOICE <br /> Sr-Z �C9, O° 1 �1 SR# jiSS� <br /> C-57 WCi WAIVER C-57 Letter of Authorrzuf ion to 5ngn pr rmit Encroachment doc— <br /> END 29-02-001 <br /> 913OV7DO3 <br />