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I SAN JOAQUIN COUNTY niDECOVED ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main StrW, Stockton, CA 95202-3029 j U N 1 b c U 10 SITE'• MITIGATION raepno.,e:(209)4W3454 Fes:(209)4sa-34Web:w NT HEALIMIT Iv WELL PERMIT APPLICATION PERMIT/SERVI NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Apphcabm is hereby made to San Josqukl County for a pemwt W corntrud wxLor install the work described. This appicMw is made in owVft oe with San Joaquin County Development Tole,dwplar 9-1115.3 and Ire Standards of San Jo"M County EnI VmnsntW HeaM Departn rt wwlumwoo 352"75 Wtify KrosssfTeet 14)'JAiway 33 ctv Verplahi S zip 5"MS Par t 5-OIS-A�� ow �j W4t✓) Hunf, r Address 3I av n Dive city vi C zip Phorhe# LS -117,64 c�coNrasew,r i IL 38 iCc� �� 5� A- city zv_ k# /- 00 Conshdferw *C,W Se l l AwT-S A)�1 Doo foaj c( 5�, fe.G1 y ()A K L A N D uc s Phone 554 6 - S t- GIs Coordiastas:X Y Township RwW Sedfon To PERfOFIfD 1�LI�Ot>wIG(CPT.GE-0PROBE,HY�oa N►A�UGER.OTHER') ❑DESTRUCTION(CHOOSE TYPE BELOW) BORINc�e 7 wv 6co P oR g� 08010 A 6 S ❑OVER-BORE DIAMETER ❑PRESSURE GROUT Cl'OTHER GROUT SPECIFICATIONS ❑EXPLOSWES DETONATING CARP COMMENTS: TYPE of wwtEu ❑MoNrroR w ❑HOLLOW STEM DIA.OF BOREHmm 3-y' ❑MULTIPLE CASINGS❑MULn EVEL WELL CASING DIA:, ❑ExTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS TYIN PE OF CASING,[3STEEL❑PVC ❑ OTHER •VAPOR ElMLID ROTARY DEPTH OF GROUT SEAL 70 RL 7 e?&gW TYPE TO BE LISED❑ALIGERSg"OW PVC_ ❑AIR SPARGEfOZONE ❑PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:❑Ye. No (NOTE MMA) N FREE-FALL DEPTH IS 30') ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS D -'f1 A'lJ 4 ❑OTHER: ❑OTHER: APPRox.BORING DEPTH 5 7 C'e !" ❑wLTED TRAFFIC Bax oft ❑STovE PIPE CONDUCTOR CASING PROPOSED a YEa,nr>rr »hn aomnrhr srteion) COMMENTS: NOTE: OFF8RE BORNM REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS 48 WONaW HOMO NO I WCE RECANIM FOR WIMCUM I hweby smAMy I IKAss and Ont t he work wM bs dons l aecorduw vift Baa JosgNdn Coady orAnarNees,Fades and so.. Tm&r-mpany Print Name Ul l I fay S ld.� k Dale DEPARBOW USE Y SITE MAP IN UNrr IV FILE, WORK PUN DATED:— APPLICATION ACCEPTED BY DATE ISSUED Y' AREA rf 2 GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE ACCOUNTM ONLY: AN)* FAC# PE CODES FEE W" ANT R>EMtTTED CH6Gtt# e Cj FtEI.'N'D BY IDAE #��o SM �oz�1 . C-57 vVC -VVJVER C57 LETTER OF AUTHORIZATION TO SIGN ENCROACHMENT DOC END 2801 1001109 WELL PERMIT APP