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ORIGINAL. <br /> WELL. PERMIT APPLICATION F(JkM SITE <br /> I MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SEf,.VIDES UNIT IV <br /> ENVIRONMENTAL HEALTH DiViSION (PHSlEHD) <br /> �j 304 E. Weber, Third Floor, Stockton, CA.., 95202 <br /> (209) 468-3449 iO1V <br /> Nora-RFVUNDABLE PERMIT EXPI;ZES 7 YEAR FRUM UATS K5SUED <br /> r.?ptiGct!:;n is hereby:nsde to San„Ipac;ui~Gauntj for a perT:it tv COnttruct anftr instal work dc:�cribed. Thi3 application is r.:ade in comptiar:ca with San <br /> uoaqu,n County 0e;ve!aprnent-title,Ghop:er`± ?I 1b.3 and the Standar.:;r;f$an ,'aaqu!n Coun:v Pubic Hieaith oervices,Envirc nrr,en:al I eaith Division. <br /> /U flssessa�s <br /> WDLL�vcaticrn [ f .7 C6C�n�rYG�/�yd 6�lvvctoss$treeet _nClsry, D �y_Zip qParue!;J _' <br /> FROp>`Rn- 1 Ownet�SCE9 <br /> co Or"� '""`�,dd ess Ov GcaC_/ O�i✓ity A4' ic«( ZiF. <br /> -.'.57 Coat',,tor -Sc �- `ll` AdjressDMj'e..c_ Ci City/ego 7J oh! 1�5I0 Prone# <br /> Ity �d�ttIC# ?go 3Y3--Phone, 7 <br /> Township P.ange: Section <br /> — I . <br /> I <br /> 1NORK TO CF PERFORMED: <br /> 18GF;lfvG(ti FT,GECHYDROPUN,H,HANQ-AUGER,OTHER") i II DES7RJCTiO'J ;cnoosc type be-!ow) <br /> Y 0$OIL BORING# [I OV=-R-BORE <br /> S �_ /;k,Al&..,.4 >,PRESSURE GROUT <br /> Gr.ut SpeoiGcaticrs: ! <br /> COnwlSN S- <br /> VFc r}F wE_L %WSTAl-LA;ON TfPE CONST R-UCTIOH SPECIF;CATIOf s e, <br /> �P.tc1N!?�RIfJC �H,-'LLO'v�l S fEV D1A.OF BORaHOLE k IVT.TIPL E �u{fi S?Q YBS A;ItiO WELL CASiNG'D{A; a - <br /> u ESTP>,C7ION A!R P.AfAM.E;!!t R1VEN- QA$1;\G THICKN.-ESS S'ch.YO TYPE OF CAtING: ©STEcL ,PVC Q OTHER: <br /> r,V+POR Fd UD RO'ARY DEF7-f-1 C'F GROUT EPLI TREMft T`'PF-TO BE UVM: []AUGERS HOSE <br /> I. SRARGE C2 PLISH P N. GP,17I1T Sa,:-L PijMPE';• CK�'es [I No �(NOOTTEE: NIAXi� FREE-FALL DEPTH IS 30') <br /> 0 S0;L G,0r,!N0 Q HARD Al Sz <br /> APPROX.BORING DEP!H 3O 70 00 Q(�.OLTE^.?RAFFIC BOX or �STOVS rIF= <br /> CON uUCT'CR CASIN-3 PRO-0SED? L' (it'YES.I'sst specM aeons here): Y- 4e& r <br /> MOTE: OFFSi T E BORINGS REQf iaRE ACCESS OR LNCR6AOHMENT PERMITS. - <br /> rfCALt_THE UNtT fV IN'-PECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> I herebtify that r hLave prepares' this application and that the v4o.rk willbe vote in accordance with San Joaquin <br /> County Ordina s Rule an - f:tatiana,and all applicable Cal',forrt'sa State Laws. <br /> , <br /> Signedx / Ti2lerCorn any <br /> ?yin'Na,rne -- �� a� ` IDa`•e <br /> DEPARTMENTUSE ONLY i <br /> - I <br /> SITE MAP IN UNIT JV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> j ETE�a o�A1C <br /> n. Of.;ation Axepted S r Date issued __ <br /> Grout!nspectrz;.E'r— - —Date__-__��—Final.In5¢ectlo, Bp ted a !'�o '�3 <br /> DcstrucEon in5oecbnn By Cate <br /> COMMENTS 1 CONO HODS: <br /> ACCOUNTING ON4Y. 11 A!D; i <br /> I � <br /> i. PE C07 rS FEE INFO i AtYICUIi;REMITTED LHEE'K# 1441D BY I DATE PERMIT J SERVICE REQUEST# INVOICE <br /> 2,q52- C#C& 12.-3 ---�--- - <br /> C-:a7 WC -WA14'6R_ C-57 Letter a; Authorization tc si5n permit Encroachment doc 9!27/40 <br />