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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton, CA 95202-3029 SITE <br /> Telephoner(209)468.3449 Fax:(209)468.3433 Web:www.Sigov OrcVehbn MITIGATION <br /> UNIT IV <br /> WELL PERMIT APPLICATION � <br /> NON-REFUNDABLE PERLLrr EXPIRES L YEAR FROM DATE ISS / <br /> t�'Y n : V �`a^^r b!<y <br /> i z. <br /> APPkJoaquin <br /> Coon NtyDOV madeto San,Chill county.3epenpt LI innsWct and/or install the work deamLed. This app6cadon Is made n1 Pompllanm vAIh San <br /> Je It Lo lion DswbpmeM Title,Chepler&7715.3 and the Standards orSanJoaquin County EnNmnmental Health CepadmeM. <br /> We It Loeatlon le// IJwsE lCeni %.la�,k <br /> Propstrttyy / t[L�.(�, 'S.Avc 4^�=Gty S62 L�/� ZIP 952/1 ParcelA 100 Igo 1"7 <br /> Asseasors <br /> tTwnerL:/va.i P.. rJ+`aaL 'l<J Add,, <br /> G#7 Cdntrac(or Clty fa S/-e,y Zlp 95'[C7Phona# A/A <br /> �_�Adp,a7aa gcG Ac _ City ca�v'+ <br /> Comultanlleul,Cnt%j�ph4a-1TL.e4"AddmS Lb k o Bona-Y2•S'El; <br /> -P--- 12YYitf is a en•e.5.4C qy CA'Lie# <br /> OIs Coordlnetes:X.39. m_ — ,Y— <br /> _ Y- 0­153 <br /> Lb# NA Plane HD-1-93.E-136' <br /> ToymRange Sectlon <br /> WORK TO PERFORMED: shlP <br /> ❑NEW WlLL/BORIHG(CPT.GEOPROBE.M' ROPIINCH,HArI GER.OTHEq• <br /> ❑SOIL BORING# 9DESTRUCTION(CHOOSE TY FSAW) <br /> p•OTHER LL# Z- 12. <br /> Z VER-BORE DUIMETr�/ t lWL I <br /> ESSUREGROUT <br /> /IK✓z-8�- GROUT SPECIFICATIONS <br /> COMMENTS:W w' <br /> v' r4e \ <br /> S T1T s CONSTRUCTION SPECIhCAT10IS <br /> AaYnONITOPoNG ❑HOLLOWSTEM `BOREHOLE <br /> ❑EXTRACTION -/✓ .❑MULTPLE CASItJGG I]MULTFtEYEL YELL CASMG DIA;�/j <br /> ❑AIRHAMMFJWgNEN CASING THICKNESS _TYPE OF CASII C3 STEEL DPVC ❑ G .ER <br /> ❑VAPOR ❑MUO ROTARY -- <br /> DEPTH OF GROUT SEAL <br /> 0M SPARGElOZONE ❑PUSH POINT{OP OR OPTA .. TREME TYPE TO BE US 11 AUGERS Q HOSE <br /> O )SOIL BORING O HAND AUGER GROUT �[ <br /> SEAL PUMPEo:Xy- O No(NOTE UMMUM FREE-FALL DEPTH M Spy <br /> GROUT SPECIFICATION"0 OTHER, <br /> �!A/�14� <br /> COMMENTS.` OOTHIRR APWtOX.WRING GIII /✓aA <br /> Y� PRO,.e AYA Y4 ay TRAFFIC BOX OR []STOVE PPE <br /> itfr <br /> NOTE: OtFSIT NGS REQUIRE ACCESS AGREEMENT 01 ENCROACHMENTPERMlT3 <br /> #s WORXINp HOUR&NOTICE REQUIRED FOR INEPECTIDNS <br /> 1 hereby nrtlfy apt I laaw Pmpamd thk oppseatlon and that the work Will be dory I ae=idanp wea San Joaquin County Ordklmsw,RYIM and <br /> Sa sons' sp,L�� Lows. <br /> PridNamemeK j'{// `� Idle/CanWPl �it, a�� -A <br /> u I_ :c v <br /> Data L _22_ol <br /> D�PAR T E Y 29 <br /> SITE N <br /> E MAP INUNITFlLE,ADDRESS: 3011 <br /> GE E Y SJx'N UST? <br /> WORK PIAN DATI -O r n <br /> APPLICATION ACCEPTED BY -"�---1 <br /> 11FD 9 oq <br /> -GROUT INSPECTION BY DATE ISSAREA <br /> _ FINAL_IN_Cac__rrinu <br /> DESTRUCRON INSPECTION BEvY - DATE <br /> DATE <br /> COMNENTSJCONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FIFEINFO fAC! <br /> AMT REAATTED CHECK# D DATE <br /> PERMR/saRVIC9/! INVOiCE, <br /> 7-m .yyANER CST MER OF AUTHORIZATIONTO 9K3N PERM -SR# 6 <br /> EHdaa liw( Ea) ENCROACHhgNT DOC <br /> YT.L7•DWRAPP <br />