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WELL PERM87 APPUCAT0N FORM SITE <br /> �OOZ w SAM JOAQUIN COUNTY PUBLIC HEALTH SERVICES Umq'T � <br />' ENVIRONMENTAL HEALTH DMSION (PHS-EH-HO) <br /> Cal <br /> 304 E.Weber, `head Floor, Stockton, CA., 95202 <br /> ��-` - - - (209) 468�4 <br />' NOI1IaUU DABLE PERWE IRES i YEAR FROM E-kAM ISSUED <br /> tppkcatton is hereby made to San Joaquin County for a permit to construct andlbr install Me wank described. This appfcation is made In compliance with San <br /> loaqutn County Development Tft Chapter 9.1115 3 and the Stand2rds of San Joaquin County Public Health Servrces.Environmental Health Dhfton <br /> Assessors <br />' YYELL Lors~tioo 1L O3 -1* 5- 7- Cross S&mt eW.4,9 TF..4 V Crty Parceig <br /> 'ROFERTYOwnereoU MdNsAddress��7� E egh'eTI;+?6"gty !9 Zip 4s-' Phorteff 209V � <br /> ;-57 Conlractor W �De c.l vG. Address A 4' jdax 414 OIty=r.,F s,Zrp±VL41 Uc9 9&tV Phane#P F/6 77 - 91C 0 <br /> nsultantlSub Contractor Address City lJe# Phone# <br /> ;13 coorchnates:X .Y Township Range Section <br />' MORK TO BE PERFD : <br /> EW WEtt.r BORING(6ir GEOPROeE.WDROPUNCH.MAND-AUGER UMER'} b1=STRUC'PIONL� Bt below) <br /> I7 SOIL BORING <br /> ORE <br /> I7 WELL B MW - _ PRESS AM GROUT <br /> TYPE 4F WELL. Ii�STAtlA4t�AME COmSTRUMM SPECIRCATMS <br />' ` 11 IONITORING AiOLLOW STEM DLA.OF BOREHOLE /w� -PAULT1PLE C4SINGS713 YES rjNO WELL CASING L71A:__Zy_f <br /> EXTRACTION [I AIR HAMMERlDRIVEM CASING THICKNESS 1c�_TYPE OF CASING [ STEEt. PVC 13 OTHER- <br /> 10-VAPOR a b4UD ROTARY DEPTH OF GROUT SEAL. TALE TYPE TO BE USED. 1]AUGERS IM-LOSE <br /> AIR SPARGE i]PUSH POINT GROUT SEAL PuwAp60. gyri ©No (NOTIE_WIAMMURP 1FREE4$ALL DIEPTH BS 30') <br /> ,SOIL BORING 13 HMO AUGER GROUT SPECIFICATION �aIV--� * ..T leo .Edd? --ro <br /> OTHER.-_______fl OTHER APPROX.BORING DEPTH O' &BOLTED TRAFFIC BOX or 1]STOVE PIPE <br />' CONDUCTO'k CASING PROPOSED? IVa _ _. if YES list specifirabons here) <br /> 'COMMENTS• <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br />' CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> I hereby cerbFy that I have prepared ttBsis application and tivat the work will be donee in acconlance W62I>t Sara Joaquin <br /> County Ordin s,Rules and Regulations,and all applicable CalilforselaSt>ate Laws- <br /> Signed x <br /> TittelCampany -e <br />' Print NamDate <br /> DEPARTMENT USE ONLY <br />' SITE MAP IK UNIT IV FILE,ADDRESS: <br /> WORK PLAIT! DATED' I I ®/ <br /> Cats Issue_ 11 1 (9 Area_ <br />' AppGcatlan Accepted By <br /> Grout Inspection By Date Fir>al InspectionInspectionFay I pate <br /> Destruction Inspection By Date <br /> COMFAENNTS 1 CONDMONS <br /> 7A7CC7OUNMM,G OPlLY. AIDS FEE m FO Amouar mMI M CHECK Y 89010 BY DATE P�llATP!SL=RVLCir RreQtJ E5T ds LtibOICE <br /> g <br /> C-57 WC -WANER_ C-57 Letter df AtfPhorixnfitan to sign permit Encroachment doc - 9/27/CO <br />