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01/01/1000 12:21 2094683433 EHL) PAGE 02 <br /> SAN JOA IN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, ockton, CA 95202-3029 SITE <br /> ' TNephone:(2D9)488.3449 Far:(2 )468-3433 Web:www siDov DrDJelld. MITIGATION <br /> UNIT IV <br /> WELL PERM11 APPLICATION <br /> ' N- -R I NDA H P MR P 1 YEAR FROM AT 1 SUE <br /> APpNr County <br /> Dn Iopnoto Tiue$OAj0aquin Coanty for a Pa"nk to CWSMO and instal the�.OR deScribed. Ynrs applirvgolt is mnyeM oompFdnoe wiU15an <br /> Joagtw CauMy OeYelapmenl TitlJe,chapter 9• tt53 jSfandara s of Son quin Cowry Envown,engl HeahR DePaltmanL <br /> ll Locav <br /> ' rtyl�� ross — -{- na:es:t <br /> Pmpp ` Ci1Y zip Perca41P i <br /> Owner fP(.{' A <br /> dlyaas O tn p Cdy y/LartI.LG0. Zip�'�_41Fhone i - � -21� <br /> caTconvacroreit� ` ; AODI955 K� l Car MaII1tk z;a5h3Licr�iSq.S P53i3-S &�p <br /> oneulgn ub Cnlr Addrass I cir,G_ , yi Cly I.Ian <br /> YtK Q LieII Phone. IIZ- Z'. <br /> GIS Coordlname:X <br /> 'y vv Range ec15on'Z ' f <br /> P <br /> WORK TO BE PERFORMED: <br /> C3 NEW <br /> ' WELUBORING(CP ,GEOPROBE-HYDRLCEl SOIL BORING@ NFUNyAUGIER,�OHIQ DTEUCION(CHOSE <br /> TYFE gELOWI❑ R <br /> ❑•OTHER RP-' � <br /> COMMENTS: R,.:L //IltirGROLTSPECIFICATISI <br /> — <br /> r4h _ <br /> i <br /> nP <br /> it Q <br /> cu <br /> ' TYPE OF'WELL INSTALLATION TYPE CO TRU 4 SPECIFICATIONS <br /> 40N170RING P11MOW SI£U OLa OF HCREN E k3" II <br /> /I,�❑MULTIPLE CASINGS❑MU!7HEVEL IA£LL CA$ING DIA �Z <br /> yQ fixrRACT10N QAIRHARWERoRNEN CASNC THC SS��IIFJ TYPE OF CASING:13 STEE L X PVC ❑ OTHER _ <br /> ywoR O NUO ROTARY DEPTH OF GRC SEAL -i r 32 TReMIE TYPE TORE USazD.WAu ERS J*CSE <br /> ❑AIR 9PAROE/020Ni ❑PU3M FOIM(GR OR�P— GROUT SEAL PU Ye♦ \e <br /> '� D� (NOTE:MAXIMUM FREE-FALL DEPTH IB 301 <br /> ' ❑SCiIBORIKG QHApAAUGER GRdJTSPECI� npNS �Q a <br /> E3 OTHERi Q OTHER APPROX.so I. r <br /> COMMENTS; COR OR y. OFPTHpC P536 X�LTEDTRAFFIOBOX OR ❑STOVEPIPE <br /> b trOMin rurm pry <br /> rn YNcnL <br /> ' <br /> NOV: BORINGS REQUIREACCE55 GREEMEN OR ENCROACHMENT PERMITS Cr- j fa <br /> 48 WORKING HOURS NOTICE R1 UIRED FOR INSPECTIONS y, <br /> 1 h°ro pdH. Ina"hav Par N(S eppNtatlon and thyt Mp Wo,k wW ono 1--Cor=ms with San Joaquin Comity Ordiluncd,Well and Grti; <br /> t Rego] and aU app, a : 1Nornla <br /> Signed rUCJC mpan, ►ILh•( LL.-. <br /> Print Name <br /> Del <br /> ' DEPARTMENT SE ONLY <br /> SrM MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED;_ <br /> ' APPLICATION ACCEPTED BY DATE ISSUED L l S ✓' lel <br /> AREA 3 L_ <br /> GROUT INSPECTION BY F INSPECTION BY <br /> CE$TRUCTION INSPECTION BY D E _ DATE <br /> ' COMWATWOONOMONS: <br /> ACCOUNTING ONLY: AID% AO* <br /> PE COOFS FEE INFO AMT REMITTED CHECK* ECV`p BY DATE <br /> PERMR/SERVICEi INVOICE <br /> Lqo T2 D JJ LG.a7Y <br /> r5 uc `lhxmP SR# �Aggnc <br /> •VVAfVER C57 LETTER OFAUn-I TI NTO$M,N PEAMIT ENCROACHMENToOC <br /> ' ego rsv Iu:m �OPi v,\$� <br /> wEµPt:RMT aPp <br /> t <br />