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T T w`h. I '16.111'%5111111 . • i- l Fr 7<t r-� a •V. � - �r <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (P -EH UNIT IV�QpQ. <br /> 304 E. Weber, Third Floor, Stockton, C <br /> (209) 468-3449 <br /> • <br /> NON-REFUNDABLE PERMIT EXPIRES'1 YEAR FROM DATE ISSLiEi?.On rs hereby pace to San.ica4^1n 6-NON-REFUNDABLE <br /> i tar a pe Tn• C Ce^st•-=an:;• ^s all he kart:escri.lte T�.ls a?auce -1 is mad_ -zonpunce w <br /> f pphca: <br /> T�.1s Ctap�a•E-111 e 3 a�.a x e 5:31aa�s a'Sal J:;,-.n Caurty F�ua��t-ea'R Serve .r <br /> Serves Er -rel a�-lealt7 Division Co.rr.'y CevalOa•zent <br /> � Assessors �, <br /> WELL Location Ql� • C•css T-ee. A11SS1Cn �C., 2p ParxlA <br /> PROPERTY O-ner-547 161,129JAutJ� .d3•ess �ivec y _�„ P�Ons• Y <br /> 14-28 <br /> C-57 Contractor_V8dn1 lY'�13 7r>g �dCress P-O- Box 51 Cry Flo Vista Z,a 9+571 L cr 7� ,=n,�e= 707 T <br /> Consultant I Sub Contractor :,toress 1186 E FxaT>e?x' SG Gi'y � tr" 51357 Pza-ez 5-0 668-53 <br /> GIS Coardinates X _ Y TD rsh o 1N Ramage 6E Serlon tl <br /> WORK TBE PERFORMED <br /> t.EY�Y►'ELL I BORING(CPT GEOPROe: hYCRC=L�:FI HAND-AU13ER OT?-ER-) D DES-^_CT-O\(--noosetypebelay <br /> 9��Tlw <br /> a SOIL 50R NG= D OVER-BORE <br /> rVELL {)PRESSURE_GRO; <br /> 'Other G•�. Spec scat ors _ <br /> COMMENTS - <br /> TYPE OF WELL, )NSTALLAT! N TYPE CONSTRUCTION SPECIFICATIONS <br /> .MONITORING �;ftlOLLOW STEM CIA C=BOREL-OLE-� S��/-MULTI-LE CSS' JGS'E3 YES 'O 1YE:L CASING 3wA <br /> ;ff13 EXTRACTION ¢+!p- 11 AIR HA1tt.AEr-trRl\'_4 CAS''JG T)-rC{-,ESSCSA yD_ TYPc OF CASING GS-EEL D OTHER <br /> a VAPOR � Q M.LID RcOTARi' CEPT4 OF GROAT SEA_,_,,YS� TREPAIE T-PE TO 3E_I-SED J AirGEFS g:40 <br /> [)AIR 6PARG.E. 13 PUS'-i POINT GROUT SEA.PUtePED S-es D No {NOTE MAXIMUM FREE-FALL DEPTH IS <br /> SOIL BORING U HAND AUGER GROaT SOECI=CA7.O'%S NMt CeTJEnt•. With 5%bMtaUte <br /> 0 OTt-EZ% D OTFER A?PRCX BCR'1%G D;= ;0OLTc't7 TRfirFiC EC? or D STOVE P.Pc <br /> C.^.,JDUCTOR�-AS\i3:�ZOPOSED7- No (tt YES,Istspect':a+rons Pere) <br /> -COMMENTS <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS 1N ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> 1 hereby certify that I have prepared this application and that the work will be done In accordance with San Joaquin <br /> County Ordin es Rul and B^ -+ -Is, and all applicable California State Laws <br /> Signed x s':.O rpany C $�rl�'S <br /> Print Marne L. Cc7tverse Da'e!1-,Z 6-A0c1/ -- - <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS <br /> !F GG. .8 5`t-'---- - <br /> WORK PLAN DATED: �� ro ZooC !rd : <br /> Application Accepted By Dale Iss%.ecl .� 3 <br /> Grout Inspecden By Date Fhal lnspeet,on By Date <br /> Destruction Inspection By 0 <br /> COMMENTS ICONDITIONS- r� <br /> ACCOUNTING ONLY. AID# , <br /> PECODES FEE INFO AMOUNT REMITTED CHECK s REC D BY I DATE PERMIT(SERVICE REQUEST p INVOICE <br /> / l C7 f-23-o► l- <br /> C-57 WC -WAIVER C-57 Lester or Authcrrzetrcn to sign pernrt t=ncroethment dot 9/27/ <br /> EO S.d <br />