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EHD <br /> ------ : r � PAGE 03 <br /> San Joaquin County <br /> r Environmental <br /> y. Health Department SITE <br /> 304 East Weber Avenue,3rd Floor, Stockton,CA 95202 <br /> t (209)468.3449 Fax:'(209)468-3$33 Web:www;eo.san-jo7guin.ca.ua/ehd MITIGATION <br /> UNIT IV <br /> NON-REF_ UUNDAULE PERMIT EXPIRES 1 Y&AR F <br /> Applloa(fon lc hereby made to San Joaquin Counly for a permit to construe OMD ISSUED <br /> Joaquin County Development Title,Chapter 0-1116,3 and ilia Standardst and/ar Install the work deeaNd. This appllcailon Is made In compliance <br /> of San Joaquin County Enwromnamai Health Department. With Sen <br /> Rfsugh./ 1b, �" <br /> WELL LocoNer r 'yQ�� ��L ' <br /> Ret - CrossS�� K fT A49060R <br /> PROPERTY -� •J -� --City ��" !p 2alParaota ' 'L-o3p -r, <br /> 4 ddmssZ-1D ( LAS <br /> -- " o,.•c-Address22o—W4'jL1 JI--AC7 _4�, <br /> 0.67Cantractor <br /> zo1 Qy( p q,4 G <br /> ip C{t 4.�w� en Yei•13M <br /> Coneuttant/Sue Cntr Cs,r.. y ff 714-W PhoneMC_68_2 <br /> ddross z IZ t j1, C,f ;,, vi o. } <br /> 013 Coordinates:X Y ClliG. -e Llc#'2b 5{CS'pnanea �zC '13t^l Leo <br /> --�.TownShlpRangO " <br /> �RKTOBE R OkMED- �Saotlon,� <br /> PEW j <br /> -WELL/BpRjNp (CPr�gEOPROBE,HYDROPUNCH,HAND.AUpER,OTHER,) II DESTRUCTION (choose typo uelox+) ' <br /> J _ d SOIL BORING p <br /> a <br /> � WELLB � DOVER-BORE. DIAMETER <br /> j1'Othor D PRESSURE GROUT —"— <br /> COMMENTS: r I R,(.--\ o p ` r GROUT SPECIFICATIQN3 <br /> r'ocw P• G. �...•-a- <br /> INaTALLMON <br /> D HOLLOW STEM PE D NST UC oN SPECI, <br /> MONITORING DIA OF BOREHOL <br /> D EXTRACY16N Pte— O MULTIPLE CASINOS B MULTI-LEVEL WELL CASING OIA: <br /> BAIR hOTA RmRIVEN CASINO THICKNESS t' <br /> D VAPOR ---��_TYPE OF CASING: B gYEEL PE TO BE U�VC BOTHER; <br /> B MUD 12OTARY DEPTH OF GROUT SEAL �nAUGERS (v`,'�_ <br /> B AIR SPARGE/QyONE PUSH POINT(GP or CPT)GROUTSEAI,PUMPED: ayes'w- OTE!MAXIMUM FREE.PALL DEPTH i5H30) <br /> D SOIL BORING D HAND AUGER OROUT SPECIFICATIONS /..'^1-No c�,N ;+ ,,.`• F <br /> J OTHER; B OTHER APPROX.BORING DEPTH <br /> .rte '♦:b� xw)r 0 BOLTED TRAFFIC BOX or(6Y0VEpIpE <br /> ,OMMENTS_` CONDUCTOR CASING PROPOSED (If YES,list 6peolfloellona In comment section) <br /> NOTE; OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. C <br /> 48 WORKING HOURS NOTICEREQUIRED FOR INSPECTIONS. <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> :otinty`Ordinances, Rules a t. eg�/Iptions,and a!I app)tcable CaDfornta State Laws. <br /> ignetl x ~ w• iC.�..� t <br /> • Tille/Cempany <br /> riot Name <br /> DEPARTMENT USE ONLY Data <br /> ITE MAP IN UNIT IV FILE,ADDRESS: <br /> 'ORK PLAN DATED: <br /> pllcati0n Acr�ptad B iu.s.Q.� ' <br /> out Inspection By •Data issued�'Z b G Are /-r,��^ <br /> Dale e 0 Final nspection By <br /> s <br /> otruclbn Ins action I <br /> B Date Date <br /> ,MMENTS/CONDITION$: <br /> CCOUNTING ONLY: - AID# <br /> F <br /> ;CODES FEE INFO AMOUNTREMITTGD CHECK# REO'DMY DATE PERMIT ISERVICE REQUEST i/ INVOICE <br /> } oI <br /> r70t-1sR# oo <br /> _ WC -WAIVER C-571-0ter of Authorization to sign ermit•9-22.00! _ <br /> Encroachment doe>2 •/ <br /> r <br /> . r <br />