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- • • <br /> ` yoR NI SAN JOAQUIN COUNTY FILE COPY <br /> z r <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 60.0 East Main Street, Stockton, CA 95202-3029 SITE <br /> Telephone:(209)468-3454 Fax:(209)468-3433 Web:www SiOOv OrO/ehd MITIGATION <br /> UNIT IV <br /> WELL PERMIT APPLICATION <br /> NQN--REF Cyd ' t <br /> )JNNDABLER <br /> E PMM EXPIRES / ""ES 1 YEAR FROM DATE ISSUED /v Yf l <br /> APPOCafbn is hereby made to San Joaquin County for a permit to construct andhX Install the work described. This a 1 f <br /> Joaquin COunty Dbveldpmeht Title.chapter 9-1115.3 and the Star 2f San Joaquin County Environmental Health Departmentade in compliance wttlf San <br /> Pro�rty ocatto <br /> n.�ZIV 5 "V ro s Street DOUGL�F.S �l :Ity �c ate+ Assessors <br /> Owners RSR - f zip 95867 Parcel#,077-y/0-29 <br /> rl Address 770b6/�p <br /> I , [lt2/PrCt Ccity <br /> CST Contractor �ka -D4. ry ' ZIP ?S22 Phone $806 <br /> Address/13P <br /> LAA <br /> nn,,ii nnzils7l,z Llcu 7bQ,5�8 Phone <br /> CoHaOUanUSub CntrAt✓7 / S Address City PJ v,' Llc# Phone G.9K�� Sem <br /> cls CooRlines.x 3$.D I p Y -IZl. 3zTr " -� vsm <br /> To nstdp Range <br /> WORK 70 BE PERFORMED. Range <br /> 4I`* f"0lL EORRN3(CPT GEOPROBE,HYOROPUNCH,HAND-AUGER,OTHER-) <br /> OIL BORING# S' _ ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> El WELL# Q OVER-BORE DIAMETER <br /> El*OTHER ❑PRESSURE GROUT <br /> GROUT SPECIFICATFQNS <br /> COMMENTS: ElEXPLOSIVES DETONATING CARD <br /> T4'PEOF.WELL MWALLA-TION TYPE CONSTRU KM A O `r\ <br /> 11 HOLLOW STEM DIA OF BOREHOLE / <br /> C MULTIPLE CASINGS C MULTI-LEVEL WELL CASING DIA:_ <br /> C EXTRACTION C AIR HAMMERAJRIVEN CASING THICKNESS <br /> -6-POR TYPE OF CASING 71 STEEL C PVC ❑ OTHER <br /> ❑M _ <br /> UD ROTARY OF GROUT SFA <br /> TREMIE TYPE TO BE USED C C AUGERS HOSE <br /> O AIRSPAROE}0117NE DPOSH POINT(GP OR CPT)_ GROUT SEAL PUMPED:C Yes 0 No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑B©R-BORING ❑HAND AUGER GROUT SPECIFICATIONS _ N � (:5 tlu y•�Y!l <br /> C OTHER: C OTHER APPROX.BOLTING DEPTH I? / !/ <br /> COMMENT$: CO ORC IIS PROPOSED C BOLTED TRAFFIC BOX OR 0STOVE PIPE <br /> N/f 1R 9E3 J4Y„ ey, ) <br /> NOTE OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT KRATS <br /> 43.WORK[NG NOURS NOTICE REQUIRED FOR INSPE <br /> I hmeby certify that I tare Prepared this apPlication and that the work will be done I accordance wHh San Joaquin County Ordinances,Rules and \ <br /> RegTdarydns;and ItE a California Laws. <br /> signed TIlleram an <br /> P r�u LSasf� r <br /> Print •e-.�- 4. _ <br /> DEPAItTMEN7 USE ONLY <br /> u� n Z9-GO <br /> STtE MAP IN'UNIT IV-FILE,ADDRESS: � �J��,•, ¢8 <br /> WORK PLAN DATED; <br /> APPLICATION ACCEPTED BY DATE ISSUED LD JC AREA W ' <br /> GROUT N1LSPECTIM BY <br /> FINAL INSPEC110N nr <br /> DffST14(ICTIONINSPECTIT3t+t BY - -- - ��V DATE <br /> DATE <br /> COMMFWSiCONDFRONS: <br /> .. ONLY: AID# FAC4 . <br /> PE CODES FEF INFO AMT REMITTED CHECK/ <br /> 613RECV D 0Y DATE PERIM171SERYICE• INVOICE <br /> C- 3D 5.310 <br /> -WAIVER C57 LETTER OF AUTHORIZATION TO-SIGN PERMIT E ro <br /> FJ1029,b1 f028A19 DOC <br /> XL4 <br /> WTAPP. <br /> FILE COPY <br />