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• <br /> COPY <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> XI 600 East Main Street,Stockton,CA 95202-3029 SITE <br /> reJephone:(209)46&3449 Fax:(209)46&3433 Web:ftn siaov orWehd MITIGATION <br /> UNIT IV <br /> WELL PERMIT APPLICATION orf -fry v- <br /> NON-REFUNDABLE PERMIT IXPIRFS 1 YEAR FROM DATE ISSUED m `Y <br /> AP"Catlon le henry made to San Joagpjn Coin•Tor a penok to W nshud angor instal the wwk descnbed. TNs apptica6on tr made In compl\/ with San <br /> JoplAn County Developmna Title,chapter 8-1116.3 and the B*Wxds a San JogI,1n CotaN�iMro ritwd. l Heald De tiDn Is L <br /> WaB Looatlon ` 1 ^ ,,BATT`• / <br /> Property -�`S]LE- �.(Aa55 Vaal V ASrI r�`�I O�/TN a (qty LK�On Asseaeal'e <br /> Ownrt•oAy� nP SZ PmcNR !00/'7Aar <br /> -r�.?_+ZAddmaa 35'S� ( F an SF„_/�, 71 9 <br /> al C-E7 Condrector AA' -Z;"i' p— � 0nel <br /> Address 9.f0{r{rl P / 8"���_" ,`aY,TS} <br /> Cornu,tanVSub Cntr�_���L� FMsam/u C'� 5 -� lk1 Y- %'°'>a 925-313-SPoo <br /> t ��tlV(/d Addnx8'Eiu2 dzy-Jid,_ pr/�k'M' �„y_fjl yy i <br /> ilcl Nh PMne 7s 7-933.13 6 ef <br /> GIS cawdineu,a;X QOS ,y <br /> Township Range Section <br /> WORK TO BE PERFORMED: - <br /> ❑NEW WFyUBpj71ryG(CPT,GEOPROSE,HYOROPVNCti,NAND-AU OTMEItj <br /> ❑SOIL BORINI39 aDESTRUCnON(CHOOSE TYPE aaOM <br /> ❑WELL I _ OVER-BORE <br /> O`OTHER PRESSURE GROUT <br /> COMMENTS:,../ 1 '�/ J, GRROtJT SPECIFICATION <br /> _— L—r_"�'�-g—'-�v�p•� <br /> ,TyyYPE OFI 1TALt.ATION TYP E <br /> S.4Ec1FICA71niS A' <br /> ❑HOLLOW STEM DW.CFBOREHptP 1V <br /> EI ExrwlcrloN —dLL�'o MLanaE cASINos D Mvtn-�vE� v.,21.cAs,NG pu: <br /> ❑NR HAWERORNEN CASING THICI(NESS, VA TYPE OF CASINO:O wEa CI PVC O arHER <br /> CI VAPOR LI MUD ROTARY -- <br /> DEPTH OF OROIITSEK A"A TRE6eE TYPE To BE USED O AUGER9 O HOSE <br /> O AIR SPARGEOZONE ❑PUSH POINT(GP OR CM__GROUT SEAT.PUMPM GO Yu O/Ne(NO/TE:IM%IMUN FEL-6•FALL DEPTH IS ie) <br /> ❑SOa.901atK3 ❑HAtDAl/GER �L•.J C L <br /> ❑OTH9tGRIXRSPECIFICATIONS <br /> ❑GTFER <br /> GOAQAt7(1$; =�O BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> ,aYas,aeiad. . _# aenMlwlnd <br /> NOTE OFFSET BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> fi WOFOUNG HOLM NOTtCB RBQUIRED POR INSPECT10N8 <br /> 1 aew0ycefflyyLlud I hm Steepened tore aPIHloWon end dN!Mn wwk WN be don t secorCllnn Wllh San <br /> -.Q iP�N p�pDlye, heVDln Coony ONYnnue.Ruble ens <br /> Ptka NenN�i� � �i t.�f <br /> Uafa �^jt?-O� <br /> SE L L9-S7 <br /> SITE MAP W UNIT N FILE.ADDRESS: �/V . <br /> WORT(PLAN DATED- <br /> Lf Q ' <br /> . APPLICATION ACCEPTED BY DATE ISSUED �•(�•0 9 AREA O v/ <br /> GROUT INSPECTION BY <br /> FINAL INSPECTION BY DATE <br /> DEBTRUCTKx.1 W.4PECTK)N BY <br /> DATE <br /> ' ODEI1111NT&CONDITIONS: <br /> ONLY: AID0 FAC! <br /> P2 CODES FER IWO AMT REARTTgp CHECK/ <br /> RECV'D 9Y DATE PBRM►fSBRVICB I MVON;E <br /> WD / 2, p <br /> awlvER C57 OFAUf110WZA-n70SMp R <br /> .taouo,„SW(wEpl °-e;�..v�PaYr"''"`�✓� <br />