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SAN JOAQUIN COUNTY PUBLIC HEALTH SEPT TION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS �Qp 4- <br /> 304 E. Weber, Third Floor, Stockton, CA., 9;5;02C <br /> (209) 468-3449 Q � <br /> NON REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> • Applrca,,on rs hereby mace to San.,Ca1;.r-+C:u•+1 for a pe•m' c co-st'_.an:; �szl� he x'.rK:escrlotd T* s apanca Cn is made -=Dnp'ja-+Ce k h <br /> Joaqu n Cojn'y Cel el�p^,ent T Ie h Se•v Ces er.r^_-*e;z -ieaR"ICIvi513-i <br /> sat's <br /> Assessor'sWELL Location 1 Cunt Club BM. C css S ee M=ai �C111 %'c� Zp P Asses <br /> U*7109 <br /> PROPERTY Owners W7 dQQgU r"7 Cas•gr� oda ess1�/DFh��el{�i �c/P�C ty _� ��n�� q Y <br /> jijit3( <br /> C•57 Corltr=01 VSW ire Aderess P.O. RDX 51 C I, Rio Vista 7_,p 94571 L c,= Tc'09`� Pho,e= 707 3 f4-28 <br /> Consultant/Sub Contactor Aed+ess 1386 E. Bemer 3; 513857 P,o-e# 530 668-53 <br /> GIS Coordinates X _ Y To rsh a 1N Ra-%ge 6E Seeron 4 <br /> OKT BE PERFORh1EO <br /> NEEv�14'ELL 1 BORING(CPT GEOPROBE I--CRC=t'1:kf 4.�rD-�L tR 0.-ER'1 D-5 •il CT C%(;-spore type bel-.Al <br /> g SOIL SCR NG 1_M a O.ER-SORE <br /> FELL Z All 4.2 70 PRESSURE_ GRCI <br /> 'Other �G o, Specicat.ors _ <br /> COMMENTS <br /> TYPE OF WELL INSTALLATI N TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING FiO_f_-OW STEM CIA C--SCR=-CLE^� VIUL`I=1L= CAS NGS7 0 YES ,SIO V,=_.L CASING D'4c2- <br /> a EXTRACTION ]]AIR HM RAER/CRl).,=N C%,fi k)G Tf-IC<%ESS CA e10 TYPE OF CASING [] STEEL DOT 4ER <br /> ()VAPOR []N,UD ROTAR Y CEPTy OF GRO.'T S��__�.� T:?Et,IfE 7vPE TO 3=t.SED D A;•IGERS x4c: <br /> [IAIR$FARC6 aPUSH POINT GROJTS:-A-PJr1P_D S-es allo (NOTE MAXIMUM FREE-FALL DEPTH IS3 <br /> SOIL BORING [I H/,N:)AUGER GF;C.1T S° CIE CA-,101S Int;CeTfnt; With 5%b�nt=te <br /> p OTFE„Z 0 OTI-ER APPRCX BORING __SOL TELA TRAF:FiC ECa or CISTOV=PPE <br /> CONDUCTOR C^S%C=ROPOSED? No (if YES I st specr:a,dons I•ere) <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 certify that I have prepared this application and that the work will be done ,n accordance with San Joaquin <br /> County Orden es. Rule a► 4 0-0-11 -ns, and all applicable California State Laws <br /> Signed x -'elcompany. wastlem <br /> P-int Name L. Gmverse Ca'e `-.ZG^,ZOc/ . <br /> - <br /> DEPARTMENT USE ONLY <br /> n <br /> SITE MAP IN UNIT IV FILE, ADDRESS �d �• LGGt.� <br /> WORK PLAN DATED: X17'd" 1/Gt <br /> Appiicatron Accepted 8y Date Iss:.ed� <br /> Grout Inspect=By Date Fhal Inspec�jon 3y Date <br /> Destnxbon InspecSon By D <br /> COMMENTS l CONDITIONS �p .. DI —O <br /> ACCpUNTING ONLY AID- TZ--. _ <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK s I REC D BY DATE PERMIT 1 SERVICE REQUEST p INVOICE <br /> rlC7 -23-4) I <br /> C-57' WC -WAIVER C-57 Letter of Aithcrticticn to sloe pern,t Encrocchrnent doc_ 9/27YC <br /> E(3 M-S-1d <br />