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PAGE @3 <br /> -0aill APPLICATION F6RNI SITE <br /> --� <br /> SRN JOAQUIN COUNTY PUBLIC HEALTH SEI MITIGATION <br /> RVICES UNIT A <br /> Yly� r;F�J-H ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 4 . 0//1 <br /> ct <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM tMTEIISSUER <br /> Application is made to San Joaquin County for a permit to construct andlor install the work described Thus aWicabon Is made in conpfance with San <br /> Joaquin County Developrrent Title,Chapter 9-1118 3 and the Standards d San Joaquin County Putft Health Se ices,Environmental Health Dnnswn <br /> WELL Locadan Cross Street /atr city S�yA �1 zo ,207 P Assessac's <br /> PROPERTY Owner �>, Address � 7'r-! � City Y6 Zip 9Sza/ Phones i ` <br /> C-57 Contractor Address G,&?c 316 Crtyl..L1;r ap 9 MlLil75+Phona#2�7�7_V <br /> Consultant/9e .Coctraelor ,p ��+' C, Address, � CRy aJWJctl F�Phone#S. _ 7& <br /> GIS Coordinates X Y Township 2/1i Range ria E Section Z/ <br /> I <br /> WORK TO DE PERFORMED <br /> D NEW WELLI BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) C;bESTRUCTION{choosetype below) <br /> Q SOIL BORING# D OVEN-L3oRE <br /> WLL# RE U GROUT <br /> 'Other Grout SpecEfications_3 S/^,X or/c./4 5� f _ - <br /> COMMENTS <br /> TYPE OF WELL, INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> {]MONITORING D HOLLOW STEM DIA OF BORt=HOLE MULTIPLE CASINGS?D YES 10 NO WELL CASING OLA <br /> AMM:ZACTION Q AIR HAMMERIDRIVEN CASING THICKNESS TYPE OFING D STEEL. 8 PVC 17 OTHER <br /> IAPOR 17 MUD ROTARY DEPTH OF GROUT SEAL IREW TYPE TO SE USED D AUGERS D HOSE <br /> p AIR SPARGE D PUSH POINT GROUT SEAL PUMPED D Yes D No (NOTE:IMAXIMUM FREE-FALL DEPTH IS 38') <br /> D SOIL BORING D HAND AUGER GROUT SPECIFICATIONS <br /> D OTHER D OTHER APPROX BORING DEPTH fl LTED TRAFFIC BOX or []STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (Ill fist SpeCdik:aLonS here) <br /> 'COMMENTS <br /> i <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCR ACHMENT 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 VIII be dons In accordance with San Joaquin <br /> County Ordinal ces, Rules d Regulations,and all applicable California State Laws`. <br /> Signed x TdidCompany G�G�eer '^�- • <br /> Pnnt Name @ L. onGCf Date - c,-/ <br /> DEPARTMENT USE ONLY <br /> V <br /> SITE MAP IN UNIT IV FILE,ADDRESS: "` - <br /> are <br /> WORK PLAN DATED: -;E-7-0/ <br /> i <br /> AWcabon Accepted By Date Issued 770 d <br /> Grout Inspection By Date Final Inspection By I <br /> Destruction Inspection By Date <br /> MENTS I COHDIlt <br /> ACCOUNTING ONLY Ali]# FArM <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# Ill BY DATE PiRMIT I=ICE REQUEST# INVOICE <br /> r-Fi7 wr -WATVl r-0;7 1 ottor nF AeItl+nriynllAn to tann hormst q/27/nn <br />