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Y <br /> l � ��T APPUCAY � ��� SITE <br /> V�LL P miTI A <br /> ` U Nle.N <br /> COUNTY pU.BLIC HEAtT PHS F- s <br /> SAN,14AQlllA1 CA.,952D2 <br /> ENVIRONMENTAL HEALTH pi1l1SION <br /> Weber,Third Floor, Stockton, <br /> 304 E.IN poo) 0,j-3449 <br /> S 1 YEAR G 15StlED de in eempCtanCe with San <br /> This a iiG9rion is tn8ntal Health ptvision. <br /> ctsndlorinstell the work d-$�ribed. 3h ite5,Ersvltonmes54rs <br /> NOra•REFUhRp! pt RiNrr acPiRE ttsn[Aunty p>I>'tlC t{ealth Sere <br /> for 8 QE[fSiit to cwstri t <br /> ppilceGGn igtleteby made to Saa110a4 a County d Vte Standards o San Joaquin Parceltie — <br /> Oevetaprn1:M71l9,Chapter4-1t7 and 5�ack ^ `P— 172— <br /> osQylnCounty fr "a" clams— Phe �tlja " <br /> Sy(,jC f�'Y1 rass Street S ,p„ ZIP <br /> 01 City -4 <br /> Ygtt,E.ocataert O G' trr pnona�� <br /> L aa�ress 3 VtyF�aJ zI s I t i 7L - <br /> �R4PT:FYr1F gti+rner $ phone# 5 �'f <br /> {I J i ` dress e Q wry�' Licrt� <br /> Cont�actCr o �v �rtC, Address 1Z SeCdors. <br /> � Rangy <br /> Cdnsultart l Sub Canirao or 7 d- Y i Z l b r Township <br /> Zt(DESTFtuct'ON(choose type below) <br /> G Coorti{nates X /�` pyER•BGRE <br /> d AUGER.D } fi R55SU E GROUT <br /> 4YOR TO ISEPF.RFORM£Q: '��` d <br /> NEW WELL f BORItyG(CPT, EOPFiDBE.NYDRpPUtJGt t.t!RN ' <br /> (SOIL BOFUNG> <br /> Q WELL q GroutSPeclfcations: t <br /> -other. <br /> COMM>rtWS' YES 1]NC WELL CASING DIA. <br /> CONSTRUC— SPECIFICA7t iIAkJLT1FLE CAS1fVG5. 1) p <br /> , E �L INSZAtWTION TYPE STEEL PVC O <br /> t{OLLow STEM CIA.GF 6CREFtb1.£,,-- E OF CASTi�EG: Sl AUGEtiS {]ROSE <br /> tygNiTORtNG Alit NA141MER1t3RIVcN GASINGTH]CKNESS�— TRErn{ETYQi=TQ 6E USED: y <br /> [�EJRp}gCT{ON .I.. p�pjH OF GROUT SSA t.�--•NATE: MAXIMUM FREE-F4LL dPTH 4S 30' <br /> ,13 VAPOR 1l tultlD ROTARY <br /> PUSH POfNT GROtTT S�tPLltdiPi=O: Yes [€ 5V7r PIPE <br /> (1 AIR SPARGE Il. GROUT SP6CIFIopTI6NS: Spt.TED TRAFFIC 8OX nr <br /> t.iAND AUGER p,PPFtOX 50piNG QEPTH f <br /> Q SO{L 8dRlNG i1 (t)!YES,list speci5oattons herej: y <br /> ,g OTtiER��— <br /> 4 pTHER:�--�— � CONDUCTOR CASING�'ROP05SD7�,.�.•— f P <br /> •ccor�MENTs: S.REQt]IRE ACCESS OR ENCR�7�►GHMEi+iT pER F-CTI <br /> NOTE: +OFFSITE BORING <br /> OR X48 WORKING HDUR5IN ApVANCE Fdfi ALL REQUIRED INSpEGT10N <br /> CALL THE UN T IV INSPECT uin, <br /> is 0 lication and that the work will be e one I ardattctr With San,loaq <br /> I hereby certify that I h2ve PrePared tYt PP ilcable California <br /> County Drdinances, S. <br /> I, uteS and Regulatlons,and all aP� <br /> TittelCarnpar+Y <br /> Date <br /> Stgrted x . <br /> prtnt Name D EPARTMENT U 5E ONLY - <br /> SITE MAP IN UNIT IV! FILE, ADDRESS: <br /> WORK PLAN DATD: <br /> Rafe Issued Gate <br /> t>7sQ n gy <br /> ApPgwcon AccePmd EY ' pate �nai <br /> trout Impel By Data <br /> flsseur +trsspectian BY. <br /> CC1sAME7'!TS t CONDMONS: <br /> _ OtCE <br /> ACCOUNTING CNL7,:� AI09 DATE PERMIT!ggRV1GE REQlJT<ST <br /> pe cooEs ni o AaAav FaMrrTED <br /> sk n perfsiit—. Encrcatlimerrt.dac� <br /> 9OZ7� OC <br /> WCC WAIV <br /> G-��setter of Author 9 <br />