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WER PERMIT APPUCATION FAM T _ <br /> SAN JOAQUIN GOUNTY <br /> ENVIRONMENTAL HIwALTH DEPARTMENT (EHO) S[p �.3 2004th <br /> 304 E.Weber,Third Floor, Stockton, CA.,95202 <br /> (209)408.3449 ENVIRONKIeA]T HEALT�i <br /> PE13MITJSE RVICES <br /> NON RE #!N>}A$l B Pa=Ritfff EXPIRIE� I YEAR FROM DATA ISSiI � <br /> Applmd n is hereby made to San.taagvin County fora pe rm t to torittuct andfor install the work described- This application is made ip oampliar>ce with$dn <br /> Joaquin Co"De"lopment Title.Chapter J-i 11r>.3 and the ftndaraaf Sart Jodquin County ErkAronmenW Health DepamnenL ( t f O –o S <br /> o � tv Assessors1 115% <br /> WELL 1 acatlorr L his ' GrgSs Street �Gi <br /> pUl f r �P r�LS l 1 �� Cita, "O. — <br /> pRORetrrr ovmGr. S :. . <br /> c-57 tfn2'�fo5 k1 City c '�'�;pQo ;ci1'Phona x65- iIL <br /> Cor;st11taWZlub Cotltrastor I l Futctress.l � ,�,V �"' Citjr_ ti Ptaons� t�- l <br /> GI.S a mCa rd Zas:Xr _.Y .Torm h;o —R�rr9F Section �I c� = ( A <br /> W TO HE PERFORMED: �r]MRUCTION Cd=st,tY1 below) <br /> a NEW WELL t BORING(CPT.C-S-OPR09E.H"et7ROPUN4H,I�WNO-AUGER,OTHER) `? <br /> p$OIL BORING Ir }VER-S RE <br /> Il 2wEt1 __. II PR$SSURE GROUT <br /> •Other. Qr�ut Spearcgttons' � <br /> MNFE_ 6'. <br /> VP9OF1N$LL tNSTALLAMONTYPE cdNSYRIJCIIQNSpEGtFtGATIONS R <br /> yttJPlrfpRiNG 0 HOLLOW STFm DIA.OF BOREHOLE_ hlUL rtPl E CASINGS?0 WS 100 WELL.CASING DLk- - <br /> a PaRACTION d AIR HAMMERlLLRIVEN CAGING THIGKNM mak, PE OF CASING: 11 STEI±t c; 0 OTHER: <br /> p VApd}� Q MUD ROTARY DEPTH OF GRMfl SEA Il 'fFtEMIE TYPET0 BE USED U GBRS O t10 E <br /> Q AIR SPARGE Q LASH POINT GROUT SEAL.PUMPED. U- N <br /> o (NoT�I NWIMUM FR E1r"FALL DEPTH IS 30" <br /> p SOIL SONNG Q HANDAUGFR GROUT SPECIFICATIONS <br /> Q OTNER [i OTHER _ APPROX.BORING DEPTH I,�-� 0 BOLTED TRAFFIC SOX or STOVE PIFB <br /> --�. <br /> CpNflUC"tORtrAStNGPftOPDSEI7?, .—=(ifYES,lcsispacificadonahare}: <br /> •COMMEKI's, <br /> NOTE: OFFSITE BORING$ REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL TYLE:,UNrr IV INSPECTOR 48 WORKIN(i HOUR$IN ADVANCE FOR ALL 115QUIRED INSPECTIONS. <br /> I hereby Certify that i have prepared this a pliCatirtn and that the work will be dune in aeeordanGe with San Joacluin <br /> County r i antes,R s a d Regulati s,artd all applicable Californ7a State <br /> -La4+r , <br /> Signed TitlelCampany �w <br /> Print Nam o G Dem -1 r I <br /> pEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDREM, <br /> WORK PLAN DATED: <br /> gPpl}eation Accepted 13y <br /> Date Issued 101) ea <br /> Grout inspecthan BY Data Final Ir:spe lon By <br /> rjES$trUttidCllnspection By t7at2 <br /> CONMI NTS l CQNDMIONS: <br /> ACCOUNTING ONLY: AMO <br /> PECODES FEEt>M AMQUNTrZMrrrED +vH>=GK R1C't1 DAi <br /> PER MrrISERV10EREQUESTIf INVOICE <br /> p d , Op 1S ` SRe 31 3 <br /> C-57— WG "".-WAIVER C-�7 Letter of Author n 0;6 gn permit—EncroechmW 4QI; - <br /> I -d L T 0 T Z9S LOL GWIJ3S I 3NU14 -I-1 I H WZ1­19 dZ T :EO SO Go qa3 <br />