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WELPPERMIT APPL16ATION F01%, <br /> 1�i1 NEI14�' - C��1 <br /> SAN JOAQUIN COUNTY` S�I���'�I�U4 <br /> ENVIRONMENTAL H1;A�TH DEPARTMENT(EHp} <br /> 304 E.Weber,Third Floor,Stockton, CA-, 95202 ENVIRONMENT H E�,I_TH <br /> (209)468-3449 ill <br /> tJC N-F,EFUMIABLE PFRMPfr WIRES 1 YEAR FROM DAYE ISSUED <br /> App6catlon is hon35y=dot to San.loaquin County Ent a permit to construct arAbr install me work described-This applicsGon is made in oomAlianca.midi Sin <br /> Joaquin County DevelopmentTitlt'.Ctt2pttrr9w1115.3 and the 9t2ndards oisan.loaquin Ctntnty lJtAmnmental Health Dep-renL <br /> rh•h� �.'fOSS$tPEBt �12 . �✓l _____�_�t�at i I t` Sy`iSl� lla <br /> tnr�u Local[ 551 5,1�[h� —. a <br /> PROPERTY Ovner OP1 rdslf Address zv <br /> C57 Cot►iCactar� Lx o ln�cidress�.'��iy�r�, �riy�.I c'dy7T�-",''� �Q'�5_..,I.;c,#sone�2�-��?�-$�'t2 <br /> Consultant ISub Contractor ZM IL Addressl 6 GrQi AV t �, ?h0n, o 251-247.E <br /> GI$Caatttlfl3t2s:X Y Towruhip Rw9E Section <br /> WOR ?ERFt)RMEI?: XDU-STPUCD0N(chooses types below} <br /> NEW WELL.1GORMG(CPT,GEOPROISS,WDROPUNCH.liANP-AUGMOTHER') XOVER-SORE <br /> a <br /> ML,BORING I PRESSURI•GROUT <br /> I7 WirLt. <br /> *other. # GrovtSpeGficativns, h/et C�rrica, _ <br /> CpMAAENI"`u i r IEIe wit <br /> lCs Cro c1� <br /> 1 <br /> 7ypg cfFELLWELL 1145rAI-LATION TYPE CONS-M—Uq 4N 5 ECVICATIONS <br /> tJtONfTOWNG A HO-Low STEM CstA OF BOREHOLE I2 l4 MULTIPLE CASINGSY Q Y�$ NO. WELL CASING D[4 <br /> khxTRAGTION a AIR HAMMER10RIVEN CASING THICla�1~SS �' tYFE OF i1AS1K� Q STEEi. �VO p oT Hoz <br /> q VAPOR MUD ROTARY or-PTH OF GROUT'SEAL. V8- -f TREMiar Ps To l3lr'LL=; `*UCu�--POSE <br /> Q AIR SPARGE p FUsli PAINT GF2CUr 9FJZL pUMPEa: Yes o ""'TE;MAXIMUM FRE ,FALI DEPTH 15 301, <br /> 11 sm BbWNG b HANDAUGFR GRovr SFEGIFicxrtoms; is <br /> j}OTHER: OTM APPRGX.80PJNG 09FTH � C dLTEO TRA,> F1C 13C1}C or - PIPE <br /> t5 rl l F�3 Q�L OUQ�O R CNG F O.imo? (if=,riot tpod-Nc9Gon5 here)• <br /> "c#Mral:rrTs:ltjo b � CaSI e.�# `w► <br /> :►2�x�Jb+ due ' `! b I*/ <br /> NQ : OFFS] BORINGS REQUIRE CESS OR NCROACHMENT PERMI S. <br /> CALL THE UNVT IV INSPEUTOR 48 WORKING HOURS 1N ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> I hereby rert;ify that I have prepared this Application and that the work will be dome in accordance With Sart.Joaquin' <br /> ,Countyrances, le and Rqul eons,and all applicable California State Laws_ <br /> Signed x tp <br /> Print Na+r+a O LOCI' Date F' 9 --• <br /> DEPARTMENT USE ONLY rf Z F Z_,FO V,51Lll <br /> SITE UAP IN UNIT IV FILE,ADDRESS; <br /> WORK PLAN DATED. <br /> Date Issued <br /> Application Accepted <br /> Final <br /> Grout Inspocoan By Dae n�l InspectloR BY Dots <br /> Cosirudw IrspecDon By / J Dote x,� <br /> COMMENTS CONDiTIr 1NS f /\ $ I f k, <br /> A000UMNOONLY' A101 <br /> ME CODES FENeo uNTI',EMMED CHECK# RP <br /> glf13�I�W 'D Y DATCA pERNrT1SERVlCEREW ST# It�VOtCl; <br /> 70 Q. � 9 2 o s 9 - <br /> G-57 WC, -WA1VER___. C-57 Letter of Auth r'izat' n o$igh permitirrtcroachkt��t dock I/�5i <br /> E -d L T 0 T a9S LOL GWIJ-1S I EIMUW WZHO dz T :EO SO Go qac <br />