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UL $ zoog COPY <br /> San Joaquin County ENVOtitv1ENT HEALTH <br /> Environmental Health DepartmentpERMjTJSERVICE SITE <br /> 304 East Weber Avenue,3rd Floor,Stockton,CA 95202 <br /> MITIGATION <br /> 209)468-3449 Fax:(209)46&3433 Web:vvww.sjgov.orWehd UNIT IV <br /> oWell Permit Application <br /> II01414tEFUNDASLE PERT EXPIRES 1 YEAR FROM DATE ISSUED t <br /> Application is hereby made to San.loagUh Cm*for a penult to eornwxt anaW Insw the work deeff1W. Milo sWeatlon b mane In car�glaro.wtlh son <br /> Joaquin Catsity Development Tyle,Chap�erl 191115.3 and the Standards of San Joaquin County Envlrorirrkernlal HeM-DepaWnent. <br /> 4111ELLLagtlorrft1Z6b 0 CII Cross Slreetol n�ryl T�Ir:�HTcv1 Zip�Sb S b.pt7t7 I -�3-x O <br /> pYaa kre{S <br /> PROPERTY ' <br /> owner uhiVaySnl Fo+'et A, Addr�a2vgl E.i}CIFItnG NECity Y ►+� PhorreAt-�QI10'3b�F�vlie I <br /> G67Carrector WDs�I p!A/�.pYr�-- Addrsss i 0.f3t`1( 33+0 CtyRlo Yts�a1 � 1 L107 0o Pnorree 'iy~ -3"14-43a� <br /> Cormhost/Subcrkr ICES_` Jiddresa 33Do_ppwcllS�4faq �w++aryV lj—GD-3 70 7 p Cyt 51E-652 3�ZZ <br /> ale Goordinstaa:Y, ��.Z Z 5 .Y —12 I,_.'t_l j? .T.hfp �+N R-W seaian <br /> WOW TO-29 PERFOMEDo <br /> 11 HEW WELL I BORING (CPT,GI'coPRo3E,HYDROPUNCH,HAND-AUGER.oTHERh E$TREJCTION (tlw" ! bob* <br /> QSO BORING a 01/ER-8081- D METER_ <br /> 'Other EGROur <br /> GROUT SPECIFICATIONS <br /> COMMENTS: MW-1 - a <br /> MONITORING i1 HOLLOW STEM DIA OF BOREHOLE,_ p MULTIPLE CASINGS 0MULT4LEVEL WELLCASING DUI <br /> p EXTRACTION a AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: D STEEL 0 PVC p OTHER: <br /> Q VAPOR (I MUD ROTARY DEPTH OF GROUT TREMIE TYPE TO BE USED: a AUGERS p HOSE V <br /> 0 AIR SPARGE/OZONE Q PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes No (NOTE:MAXIMUM FREE-FALL DEPTH 13 301) <br /> a SOIL BORING a RANO AUGER GROUT SPECIFICATIONS <br /> 0 OTHER:_- R OTHEP APPROX.BORING DEPTH a BOLTED TRAFFIC BOX or (I STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list sped6rsUana In coiwnent w%on) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> 1 hereby certify that I have prepared this application and"the wont will be done In accordance with San Joaquin <br /> CountyInancae. Rules and Regulations,and all applicable California State Law& <br /> s; x CJ TitkJGprnpsrny Erol4e e4 M A Ina &V- <br /> Pr.,t Warne W t vt Date _2-o o <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS- 1A <br /> WORK PLAN DATED: T <br /> Appl osUo n Accepted By Date Issued�� Area <br /> Grout ftp Kbm By ate Final tnspeWon Bye-�--• <br /> Destrut4on InVection By Date 2VIU10 `F <br /> COQ I CONOUMM: OT Or <br /> ACCOUNTING ONLY: AID* FACT <br /> PE CODES FEE INFO AMOUNT ItEMITTEO CHECK i RECID BY QA M PCRMITI SERVICE R&QUasT r IWOi= <br /> 3 a �- , SR# D <br /> C-57 WC_WATVER C-57 Letter of Authorization to sign Permit'_Encroachment doe <br /> EHp 29.02.041 <br /> 6ajV4 <br />