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•O9/. 02/20013 10:21 2694683433 EHD PAGE 04in cou"tY <br /> (�a[ <br /> c AEnvilronn I0, �1.Health Depalrtme t o 1T� <br /> 30�€Esst Weber-Avenue;.3rd F100r 5to- on,CA._9�� IGATION.' <br /> - <br /> (209)468-3449 Fax:(qO9)468-3433 Web'W�vw.SjBov.0191chd 'UNIT IV' <br /> o We11:Permit A.p.pllc Ifii n . <br /> HOH,REFLINI]ABI,E PERMIT FICPIRE$7 YEARFRL3N DAT£IS3FAM.RbwtNi if LTH <br /> -- -;- - &Il-the worl�described-. . in complsance nth San <br /> AppliCaEEon is hereby.made to sari,loaqu[n Gountyf�5r a f7egmrt to construct andror-install �PEiPPVL — - <br /> doagcsin Cnuntyr DevetopMant,7itle Chapter 8-1115 3 and ih0$tanda�d&of Sen Joaquin Couniy Enirironmenial.HaaEth I7epartment $essor' �,2.28.£7.1'3 <br /> Rose Marie,` Ci 6cQQiicn Z1p 95207 Parcel# <br /> �1lELl tocation 4531 -PaCitid, avenue/Frontar Torsstrept city,, -- <br /> PROPERTI' 4532 Pacific Ave. G y St 4CktG43. p_SS207 Fhone# <br /> 04uter paaar S2nchez Address S7�amanp�xn9e 984359 530 644 1609 <br /> A71 Wel] AbardonymeIt 6626 Merchandise way. 95619 <br /> CoitSuantractor <br /> Rddress City Zpu� <br /> C-0 C <br /> ItantlSuhCntr.- v Y Address 937 Skam Rd City Sto-- °kt°n l�C# 5an���_ Phone# [ao a67- 6 <br /> Township <br /> CIS.Coordinstes:X Y Range Section <br /> wO ra 13ERFORDESTRUCT ( e type <br /> 0!ff1W WELL'1 BARING (GPT.GEOPROBE t-IYQROPUNGH,t4AND-AUGER,D11 7HER*) OVER BORE! 131AMECTEc$ 6}rich below) <br /> �}SOIL 50RING.#.: 1HPRES$UREGROUT. <br /> p VVEtL# GROUT SPEGIi 1C 4310NS p 1a <br /> p-Other _ <br /> COMMENTS: <br /> pE tfVEI NSTAL TION PE CONSTRUC T1QN SPERFICA N& 2 inch <br /> �FhONITORING 38.HOL`LOW STEM DIA.OF BOREHOLE_ n MULTIPLE CASINGS MULTI-LEVEL WELL CASING PlA <br /> 2- <br /> inch <br /> n TYPE O=CASING' U STEEL Q PVC 0 OTHr-R:_ <br /> VEN C}SINGHIGKES$ <br /> EXTRACTION 13 AIR.HAMMERIDRI � <br /> TREMIE TYPE TO BE USED: U AUGERS CHOSE <br /> [] <br /> VAPOR. - a MUD ROTARY DEPTH OF GROUT SEAL„„„ DEPT�1'!S <br /> lI AIR SPARGE?OZONE (]PUSH POINT(GP or GFT)GROUT SEAL FLIMPED: a Yes n No {NOTE:MAXIMUM FRES-FALL 3[1') <br /> (1 SbIL BORING a HAND AUGER <br /> GROUT SPECIFICATlt;7N3 <br /> OT,FiER�� APPROX.BORING DEPTH, .p BOLTED TRAFFtC BOX or p STOVE PIPE <br /> ©OTMEI���--�Q if YES,Ii9t specifiCzVons in mmm2nt section) <br /> Cot4gUCTOR CASING FROPOSED C <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGRI=EMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICIa REQUIRED fOR IFS--PEC'TION$. <br /> this application and that the work will be done in accordance with San Joaquin <br /> I hereby certify that I have pre{aarcd <br /> County Ordinances Rule and egu <br /> RlatlonS,and all applicable California State Laws <br /> ' 71tlelcompany Y lap! <br /> Date <br /> PrihE Name - <br /> DEPARTMENT USE ONLY <br /> SITE MAP INI:UNIT IV F)LE,ADDRESS' j i l <br /> WORK PLAN DATEp: 'S a <br /> Date Issued L Lc <br /> Applloatlon Accepted By Dale I=inal Inspection By Data <br /> Grout lnspection.By <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONI]ITIONS' <br /> ACCOUNTING ONLY: AID# FACS <br /> PE CODES FEE ED INFO AMOUNT REMITTED CHECK 0 REG`D BY DATE <br /> ff PERMIT 1 S� -�J <br /> E}RVrcPRrE(2UFST# lNYQ1Gfi <br /> D fv�:vD Gt o( �Cz JL1 �F fa f. R ]C! t <br /> 3. <br /> C_ 7_Z c WATVEp— C-57 Letter of Authorization to sign permit Encrouchment doe^ <br /> E1D r9-02-001 <br /> Gl22104 <br />