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pp -11; - E2007 : .7,2F FROM : ENPROB 15325892272 Tr, • 191696E2'1=7R P.3 <br />San Joaquin County <br />FILE COPY <br />Environmental Health Department .,:// '5 n SITE <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95-E 10i \:::-") L--=; Liu ---11eTIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.orgiehd UNIT IV <br />A P R 2 3 1.007 <br />PROPEY, , , <br />Owner Co <br />RT <br />t t- cv L4,0.4 Addrues Id 62a MATher• 1Lid City Histi4ge ZIp154.0 Phontralt4 3g1 13/P. <br />C.S7 Conlractor Py4a Addreis Po Sot 6673 City 101/se Zip,trii Lit* W70D7 Phonails3059120 11 <br /> <br />onsulte21)/ Sub Cntr Ve.4/15019.4 inc. Addrals?,rityttikrie i4 7 cityAit0a1.51 LIG* Phone* Yi4 f6313Z‘ <br />GIS Coordinates: X Y , Township Range Section <br />WORK TO 13B PERFORMED: <br />a NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') 0 DESTRUCTION (choose type below) <br />MSOIL BORING* Gseld c5132.1 Pc ly 6'46 zi 84(.3 °OVER-BORE. DIAMETER <br />a wELL* I] PRESSURE GROUT <br />0 'Other GROUT SPECIFICATIONS <br />/e.fyiee-e-Y ) adadt-e01 Clet0 S-a9fA4€ <br />INSTALLATION D'PE CONSTFtUCTIQN SPEC17CATION$ <br />° HOLLOW STEM CIA, OF BOREHOLE R. I. 0 MULTIPLE CASINGS a MULTI-LEVEL WELL CASING CIA. <br />0 AIR HAMMER/DRIVEN CASING THICKNESS A./4 TYPE OF CASING: a STEEL a PVC 0 OTHER. <br />0 MUD ROTARY DEPTH OF GROUT BEAL FAX TREWS TYPE TO BE USED: fl AUGERS OHOSE <br />'PUSH POINT (GP or CPT)GROUT SEAL PUMPED: I] Yee Xhlo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />(I I-LAND AUGER GROUT SPECIFICATIONS ,vd.‘r c • mek..r. s Y. Gi-pn,,,n <br />p OTHER APPROX, BORING DEPTH .5%, If ' El BOLTED TRAFFIC BOX or a STOVE PIPE <br />CONDUCTOR CASING PROPOSED No (II YES, list spectilcations in comment section) <br />COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br />eve pre red this application and that the work will be done In accordance with San Joaquin <br />ulea ulatIons, and all applicable California State Laws. <br />MviL It/Pogog <br />Well Permit Application <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSftigiIi1RONMf:.NT HEA <br />1>1 <br />LTH, <br />Application is hereby made to San Joaquin Counly for a pemilt to construct and/or Install the week deecribed. :Ttiliappliltettatf le`'n1-6:6 a In compliance with San <br />Joaquin County Development nits, Chapter 9-1115.3 and the Standards of san JOeduln County Environmental Health Department. <br />*WELL Location VOI 0 4-1,pe dtr Ishii cross Street /71/11 .1 4 PP City <TC)C. kr0 tel Zip 15266 AsPa6rcee la /77260071 <br />COMMENTS: 4-3v 44t.4 <br />TYPE OF WELL <br />a MONITORING <br />a EXTRACTION <br />VAPOR <br />0 AIR SPARGE/ OZONE <br />zsoa. BORING <br />O OTHER: <br />I hereby certify that <br />County Ordlninc <br />Signed x <br />Print Name <br />Ttia/Company <br />Date 10 IVO -1 <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 8010 5. atAiae-zA, <br />WORK PLAN DATED: <br />ApplIcatIon Accepted By Dale Issued <br />Graul Inspecilon By <br />DeelnictIon inspection By <br />COMMENTS / CONOMONS <br />Date <br />Date <br />Area O6 P5/' <br />Ftnal Inspection By Dale <br />Z9. 6 6 <br />ACCOUNTING ONLY: AID* FAO* <br />PE CODES FEE INFO AMOUNT REMITTED CHECK* RE= BY DATE PERMIT I SERVICE REQUEST * INVOICE <br />N° i 625 81 / a 219 CJ(/. Y S " taji .3-19 - ,„ <br />C-57_L WC 1,7-WAIVER <br />DID:9-02 001 <br />6[2261 <br />C-57 Letter of Author zation to sign permit Encroachment doc