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WELL PERMIT APPLICATION FO'R-"M SITE <br /> 1 MITIGATION <br /> ;^ SAN JOAQUIN COUNTY PUBLIC HEALTH SEF VICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS�EHD) <br /> R 344 E- Weber, Third Floor, Stockton, CA.., 95202 -- <br /> (209) 468-3"9 l� <br /> NnrJ RE'PU9vDABLE t?Eh'_MIT ExarltEs•t YEAR FROM BATE,1 3SUED <br /> A:�pllc*td.,ri is heref_;'?:Wade to S,r.Jc.zQu;r.County for a permit to Cons:~uct and/or install t:he work described. 'This application is made in compfiarce with Sar, <br /> jaaqu,ro Gi-?Lnty Development Title,Ghcpter 5 111-5.3 and the Standar-F Of Son Joaquin County Public health Services,Envi.-oprental Haaith Division. <br /> �1 I+ssessars <br /> Cross StreSt <br /> FROF'EC''4.Ownei 0_l70��J"7`7C'N ��- Ad0ress 3r5 Al, � Ci'� �� Z!1 Phone# <br /> C-5?contractor �s e�� AY/,�Address_36.?A 0-IC-f- Cr%r�� city/P� 7i&?YALic# ,--4SY0Frone //�q <br /> :n Tsui onf/S�6 �.Jilr4�4tQr t3- 'ev- IQY _ Addre5_ 1.3 ,4: ^Ity/� Ic l Phone#777 7� '3.'<5�' <br /> 'Y�,- T p6vnship Range'. <br /> Section <br /> WORK TO CE PERFOFUMED: j <br /> (CPT:GECPROBE,HYDROPUN,-H,HAND-AUGER,OTHER") i j[DEVrq JCT11ON (cnooso type be!ovr) <br /> U SOIL BORING# i OV:=R-BJRE <br /> 'VI-AL /t/L 4/- -Y PRESSURE GROUT <br /> "C7tr @r: Gmut Spedficatinns: I <br /> a- ELEF We_LL IMSTAk.11-A-2014 Tt(PE CON5TF UCTION SPECiFiCAT_IONS <br /> XMONITJRING- J(H,'.LLOW STEW. 01A.OF BI-TREHOLEg" MULTIPLE vA,-,:N Sle YES 'P NO iIVELL CASING:DiA; <br /> E-!PACTION a AIR I3AM%1°ER'DFtIVEN CASING-1HICK*,-ESS CSA= `r0 -r`!PE OF CPAING: Q STEEL APVC p OTHER: <br /> VAPOR fv LID ROTARY DEP'H OF GROUT 3EP1 b S_ -TREMfE 7'``PE TO BE USt0- D AUC-ERS WHOSE <br /> I]Ain SPARGE (-i PUSH POii4T GROUT S.=AI Pia°.P5P i- Kees [l ra4 (NvTE' fi1AXIMUfA FREE-FALL DEPTH iS 30') <br /> it 30 L 50R.!NG Q HAND AUGER LROGT 5F' •^•ir'!CA.TIONS /Z ell-e21+�•�e <br /> L;Q7f IER:�_ —0 YYtiER _ APPROX.BORING DEPTH ��i OLTiE TRAFFIC$OX or 6 STOVE PiP= <br /> CJNDL;uTCR CASING PRO+IOSED? �� t i IYES,I!at specifications here;: eySt�T <br /> ------ NOTE: OFFSITE BORINGS REQU,'RE ACCESS OR ENCR ACHMENT PERMITS. - <br /> -CALL THE UNIT IV IN SECTOR 4811 ORKING HOURS IN ,ADVA.NCE FOR ALL REQUIRED INSPECTIONS. <br /> i hereby ce,tify that i have p;eparcj-c' this application and that the work wi'1.be co7e in aeCor'dance with San Joaquin <br /> County('rd!',M - les and R ations,and all applicable California State L�ws- <br /> Signed x _ /J Ttler'Company .S�'�•`50►' <br /> grin'Na,re �/CXl-°\ l _ _ Date --7 ` - <br /> DEPARTMENT USE ONLY <br /> i <br /> S:TE MAP IN 11t ;T lV FILE,ADDRESS: �3 <br /> WORK PLAN DATED: <br /> i <br /> jyp!h-;ation Accepted S�. _ — -- Date rsvued � i Are2 <br /> Grovi!nsNsc':,,Ey- --- ---_ Date _ Fina:lnspv don,By IGata� <br /> Destructor insoactior.Ey pa a <br /> C+ MMENTS 1 CwONOMIONS: <br /> T—,—--- - -- <br /> ! ACC0'JNT ING:ONLY: 11 A!r/i <br /> PE COMES FEE-INFO i AMOUNh REMITTED CNEC.;K tl � REVD BYDA E RERMIT I SERVICE REQUEST# INVOICE <br /> C-37 WC -WATVcR,_- C-57'1-letter or AfJt' c\rizafiorl to S;sn permit Encroachment doc 9/Z7i00 <br /> i <br /> • I <br />