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COPY <br /> SAN.JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> 600 East Main Street,Stockton, CA 95202-3029 MITIGATION <br /> Telephone:(209)468-3449 Fax:(209)466-3433 Web:www sjoov.or ehd UNIT IV <br /> WELL PERMIT APPLICATION <br /> NON-REFUNDABLE PERMIT EXPIR T YEAR FROM DAT ISSUED wDCALIA4 tz <br /> 02CgM Go k hemby made m San.ch,,L County for v pertnH to 00n3Wd and/or InSW t6 Work descr@ed. This apprication b made In compliance whh San <br /> , Co�taday-O2av�elaomerd See.d�adMJ�.tly.3 ord the Slanda d,o(San.baquin Cady EnWunmentai Haan DepeftenL <br /> LocatldRcl.!l� syJ °tt' .��. ` '`�`� ( .5)`L �c�e,. Assessors N/4' <br /> Ny, - hY V V - nor 9� Pa ce% -fes � - r?' c� <br /> owner teas 1174 V.9C..l.�lr� <br /> � CkY.� = Lor TSl.oi P)gtret 209_4Y8-`TPf I <br /> dMU TGs7cntraceo. a y> 5A <br /> _J" ne <br /> ComelbAzubna. ,s4 Phone i4d77-.59.;3133 S-43db6°9a7v9 - <br /> GIs ComlttmUC X 38•CDS ,Y-I2-I.352 ,T°wnahlp <br /> Range Sectlon <br /> WORK TO BE PERFORMED: - ,v <br /> 11 OWEL� %(cvr.GEOFnOe •HYDRGPOWK W Auam oniew) .Ly DESTRUCTION(CHOOSE TYPE suoM <br /> Q WELL.%_ - ❑OVER41ORE DIAMETER <br /> 0 ,LPRESSURE GROUT <br /> GROAT SPECIFICATIONS <br /> COMMt]TT$; I✓c I�S ✓r.�j�c n�� fact-.,. ..� �( I � L bo � t h L Ir <br /> TYPE OF YYELL INSTALLATION TYPE CONS IROO 002EECIMATIONS <br /> AMONBORING ❑HOLLOW$Taw DIA OF BOREHOLE A O MIATIPLE USMS O MULTHEVEL WELL CASMO DIA: <br /> ❑EX1RACixIN O ART HAMLQ:RlpRIVEN CASMG THICKNESS A-A- TYPE OF USING O STEEL ❑PVC O OTHER <br /> O VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL .` <br /> . _TMNE TYPE TO BE LISED O AUGERS O NOSE <br /> O AN SPARW=ONE O PUSH POINT PP OR CPT)_0MOLIT SEAL PLINPED:i're. O No(NOTE:MA%WUN FREE-FALL DEPTH IS 30) <br /> OSOILSORNG OWWDAUOBR GROUT SPECIFICATIONS <br /> _�(1�F[,(yI CCAGn r <br /> O OTIEIC ❑OTHER APPROX BORN$DEEPS TTH1t .V.4 O BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS, COIQ1Cf01t GiI1fT••^-w-- —cc__dfmkst'adllubnh.m ws. <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORIOMG HOURS NOTICE REWjWrLM RISPILLUMNS <br /> Ih oarey Ura be &M <br /> $TOB'° � Wad Lhb& Wkatlon MW that the wwwit be wbe done l accortlmoe with Rawr <br /> oagvin CvbMKiaa,y OfdiniTRWM and <br /> PPM Noma sr /+ , - �ITvla 6-17-v 9 <br /> DEU8 ONLY <br /> SITE MAP IN UNIT rV FILE,ADDRESS: <br /> WCMX PLAN DATED �fq - <br /> APPLICATIONACCEPTED BY DATE ISSUED • IQ•Oq AREA <br /> GROUT INSPECTION BY }INAL INSPECTION BY <br /> DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> SONS: <br /> ACOOUKTIMO ONLY: AID FAC% - <br /> Pfi 0ODE3 P!H IMF❑ AMT REMITTED CHFC1(% RECV9 SY DATE PERMTIliMVICE R R vom <br /> 6 ZO SR/ <br /> -,AWVF.R ZPERNTT <br /> HlDbet „am y.� <br /> a1/fi .5f-005 <br />