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N Sale Joaquin County <br /> Er .-anmen.W Health Departme, SITE <br /> Cv 3D4 F,as1 WcbcrAvenue,3rd F[ooT,Stockton,CA 95202 MITIGATION <br /> (719)468-34-49 Fax_(209)468-3433 Web:www,co.san-toayuin.ca.usrehil UNIT IV <br /> � r - <br /> �a <br /> NOI~I-REFUNDABLE PERMIT EXP?RES 1 YEAR FRDrADATE PS-SUED <br /> T Applicalion it hereby made fo 5-�Frr Joayun Cly for a C xnA to construct andlbr iralait the vm&described. This appiimban is Made in oorroance with San <br /> .� Joaquin Counly DeuelopnvM Tile;Chepler 9-11133 and the Nandarcis of San Joaqun Cauiffy Enmonmenlal t-{E'tMllh Deparimenl. <br /> T c� e�+ Assess <br /> WELL Location p f�"%.-lo 07 V._4 i-.1 F-s-cross Slr�wt City C, c Zip s parcels 'l 0O D��� <br /> 0 <br /> z PROP p F i <br /> ORM &�-e�_C �i�--G 5t- Address'Z2 c'�t lr�- �•r4=�,J►-City 4 �cr fzip 9qpr�P?ions0 Z--m 0244 <br /> Cis?Garrtrarlor #-�f��p��C'�t5' <br /> Addressa + Ciy�ooi�•-+�uLIC��3-�3"�Phone� "3 beg"2`�Z' <br /> GonsuICant 1 Sub Cn1r G �? Address_14t�,0 r r+'+Q re► Cily L F I� LiCa �4S Phone@ �i`Z �b''�6�cs <br /> `i-r- 3to <br /> GIS Qwd'nartes X Y Tovmshp Range Sedion <br /> WORK TO BF PEWORNED: <br /> p NEVA WELT.t BORING (CPT,GEOPROBE,HYDROPUNCK I-IMM-AUGER,OTHER) �ESTRUCTIOI+Ii (choose lype below) <br /> o SOIL DO 9 OVER-BORE. DIAMETER I <br /> d WELL R fl PRESSURE GFOUT <br /> []'Other GR0LJ7 SPECIFICATIONS <br /> COMMENTS.- <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPE?C7IFICAT30NS <br /> fW6J-W"TORING -B HOLLOSTEM DIA OF EIOREk#7LE d MULTIPLE CASINGS U MULTI-LEVEL V1 el_CASING DIA: <br /> f 0 E?{T#2ACTlON 0 ASR HAIL &R(DMVEN CASIRG TKCKNESS TYPE OF CASING O STEEL O PVC D OTHER: <br /> a VAPOR o MUD ROTARY OE€'M OF GROUT SEAL TREMIE TYPE TO BE USED Q AUGERS Q HOSE <br /> a AIR SPARGE(OZONE O PUSH.POINT(GP or CPT)GROUT SEAL PLIk1FEI), p Yes p too�N OTE: MAXIMUM FREE-FALL DEPTH IS 31)') <br /> a SOIL BORING 0 MANDAUGER GROUT SPECIFICAT€ONS <br /> Q OTHER: a OTHER 41PPROX.DOMNlG DEPTH ll BOLTED TRAFFIC BOX or p STOVE PIPE <br /> [ 00NDVCTO CASING PROPOSED (d YES,list WcAcatlons in oorrrroenl beciion) <br /> COMMENTS: e! <br /> NOTE: OFFSITE 13ORI NGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS KOTICE REQUIRED FOR INSPECTIONS, <br /> hereby certify that J hate prepared this application and that the work MIL be dont;in accordance with San Joaquin <br /> Go untyOrd ina nces,Rule d _egulations,and atl applicable California State Laws_ ` <br /> Signed x Tille,hC�arrty `i ¢. f sT <br /> Prilt Name ` t1 CL.^ "-L-r Dale <br /> DEPARTMENT USE 0 N LY 11 <br /> SITE MAF IN UNIT IV FILE,ADDRESS: V T , E <br /> WORK PLAN DATED r L)12,L1-/ c21 13 J <br /> QApplication Acwptad By. � Da*lssaed 112-410-7 Ama117-r/ _� <br /> c Gror.l€kvq ion By Date; Final Inspedion By D be <br /> - - DestruWurr htspedion By Dale P7 <br /> C0MrmEmS I'CONDITIONS: vbW <br /> r� ACCOURTING ONLY: AID0 F <br /> O <br /> a <br /> N PE CODES EEE INFO .AMOUNT REMITTEd CHECK 0 REC'p BY DATE PEMWIT I SERVICIr REQUEST A rNVMCE <br /> ,>a1417-00— ( /o /l>1 14SR#�� �, SR# D o S v <br /> C--4 C-57 WC -WA1VER_ C-57 Letter of Artthorizati-an to siert permit Encroachment doc� <br /> EUD 29.0.00] <br /> 913anoaa <br />