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<br />alltribio Party 6c:TC:C4.)6.6....",ii- e'd A /by 5,9cer.") zo 750/6 phorlo 1/,6 -442s--4g,o/0
<br />GIS Coordirrates 1c7 .7 e y (VC. vJ 7
<br />SAN J OAQU IN COUNTY
<br />ENVIRONMENTAL HEALTH DEPARTMENT
<br />SITE MITIGATION
<br />LOP
<br />6C0 Ea Si Mast. SloCkIQn. CA 95202-3029
<br />
<br />UNIT IV
<br />Telephone: (209) 468-3454 Fax: (209) 46B-3433 WPb: WWV: sltiov.ofq/ChLI
<br />WELL & BORING PERMIT APPLICATION
<br />FOR WELLS AND F3ORINGS USED TOR CONTAMINANT INVESTIGATIONS ANO REMEDIATION
<br />NOTIREFUNDADLE PERMIT EXPETI-S I YEAR FROM DATC- irs5UED
<br />ApcicakIn s hateby mods+ to San „tneallir CuI IN a ponnit or. : war'. (Tots:nb-ec.1 i his applcatiog 15 mode In compliance YAth San 110 Count,' L.Fivair.ipment TIPP Chaptei ci•1115 And the San Ii! 121 CD.irr4,' En't,i3Ontni3n14:0 Health DopLiit
<br />Silo Location I 09 $• Vellet-614firptCic14,1SIteei KA 9% 0444
<br />Prnporty
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<br />Owner 517g-tA Vz-toi_4•Aci(c.frooYtir... 1-12-.5N. El 1.civac (45 Sfocic(e‘ 74, (111,9/ Phan°
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<br />DESTRUCTION WORK TO BE PERFORMED1
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<br />Vv'El...13
<br />GROUT SPECIFICATIONS
<br />/RtmIL 11Th FO BE UFO : U ALIGIFfilS 0 HOSE rFilii-7-1
<br />CC1.4MCNTS
<br />DEL,TIlLIC TL,Dt4 METKOILatiL i ...: i _i_ 71-A 7 NV-..'il
<br />il (r,.FR iloRE oicoLIETER of .t.:crIE: T.:, eeil - i',. 17 171 PE:ESSURE GROUT romp: mot I - r 7t (:',.: imrAell
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<br />5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS
<br />I hereby certify that aar liii applIcnNori min that thn wort will tio eone In f.cr mnunco wit', San Jompiln County Ordinances, Ies nri,I RegulatIo.vs. 25,,,,,fra • iitrlo for iln laws,
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<br />DATE
<br />1iN4L IN5FECT 'ON
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<br />FiE3CV'l)
<br />(0
<br />t 1,VAivE P. 'I 1rj. OF AU ?Allot,j riFtat,T
<br />CONSTRUCTION WORK TO BE PERFORMED!
<br />t•IEW I.VELLMORING it. ty
<br />CLLL 111,/
<br />CONsTRUcTION SPECIFICATIONS
<br />DIA x .,1 4C.kri'lq.,..: 0 }ANL TIPLE CAS!HC; 5 1:1 M,LT:.LEvEL '.'i,..ti. casiaL;cia•
<br />2 ' ' repE of CA15INO- 0 STE El. gpv;: CI o-rt.,;::R .
<br />I 3 ' .11,10.VI: TYPE 10 DE LI .i,. ::. 0 AI.A...1:14.- p...i1C,:i: 0 tiii,•'E
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<br />5,,,') L TE D TRAFFIC F.CCr OR 0 STOvii. PAPE
<br />,. ,, f)-,'. , 13 , i *i ,y,C pui COMMEN T S .4Llt -el'''. . — „CPA' of _IAA:AAA/6f
<br />NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS
<br />DEPARTMENT USE ONLY
<br />still MAP NUN:" IV ALE E ADDRESS We-1>Pr t L tne,
<br />WORK El PI AN DATED
<br />APPLiCATICN ACcEt'i I
<br />Cik()Lt r 1,Lc -1
<br />DESTRO:Tin/. .11ON Ely
<br />COMMEN TS.CONOtTIONS:
<br />DATE I SERVICE I RO# yolc E REOUES T PR 4 6 i / I L71,/ SRI/ z_15to
<br />RC) #
<br />L.3500)
<br />PR V
<br />2,FleD0)
<br />c17-4.-1 105
<br />U ortirr; 1(1.:
<br />4 I'l, 1 I
<br />IvEE,14.h. OF WELL,MORIvs; 11151-ALLA TION TYPE
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<br />VA nor/ wale. n KrAlti:i:;t•ntiivi- I,
<br />vAPoR PRCRE LI;171 POT/4,4Y
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