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�^ WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> Q SRN JOAQUIN COUNTY PUBLIC HEALTH SEF�VICES UNIT IV <br /> C ENVIRONMENTAL HEALTH DMISEON (PHS4EHD) <br /> F 344 E. Weber, Third Floor, Stockton, CA.., 95242 13 <br /> (�.49) 4fiS-�3�3 <br /> �> 2 <br /> c <br /> NOW-REFUNDABLE PERMFV ExPMFS I YEAR EIKQM DATE 035UEi� <br /> A: ,icon,r)is hereb=y made to San.ro?uui^Countf fer a per,r:it to c0i :-!uct and!ar install'L-ze work described, rhi:application is rnadg in compiisrcd with Sar, <br /> JozgU,r,COLInty Dt;tvaioprnent Title,Ch,3pter�r I 1115.31 and the StandarzF of San_'aaquh County public Health Services,Environmental H*aith Divis;m <br /> y,,'ryL Lo�aiiCn�/ �- � _cross Street P�-t4rA.4 _City,-C7vc Zip Parcet:.t <br /> FR0Pi✓rn- 1 Ownet _J (,0()nI CGUZi� _ Phones <br /> C-57 c^nt 4ctor �Q-SG L R iddre5s�63�0 � G`er/Lclty, <br /> Bonsai:ant/S�6,C.�:traitor 'rl`�`!L_Ic �� <br /> vis Coo :r:atEs:h 'Y� —_ TDwriship P.ange' Section <br /> WORK TO EE PERFORMED: I <br /> AlE01VVE'_!.i ROPING A(CFT,GEGPPOSE.HYOROPUN:CH,MANC-AUGER,OTHER') i D DE$TRJCTiO!q ;choose type be!ovr� <br /> U SOtL F30rcING i# D Ov-=R-BORE <br /> Aq k/- — ! 13 r-RSSSURE GROUT <br /> `CJ'.i;er. ^--- _-- Grc:1t fipecificaticrs: � <br /> COMMENTS <br /> "PE2F WL LL_ INSTALLARON TfPE CONSTRUCTION SPECIFICATIONS <br /> 04.101,4IT;-DRING 9r1OLLOW S'I-EtY. DIA.OF BOREHOLi c/ W? TIPLE-I AS:Ni 57[}YES P O VVELL CASINrG Dih:- •�/� <br /> it cAf'RACTION 11 AIR HAMN. R'')P- IVEt' CASING THICK":ES?Sck YO TYPE OF CPAING: D STEcL g?vC a OTHER' <br /> E?v+;POft D V.LIu RO; ftY DEF OPG -OUT GeE _ 6�S' TREMIE T`-PF TO BE t1SEfl: I]AUGERS XHOSE <br /> {;Atfi SPARGE F_�PUSH PONT GP,OUT SEAL P'tiMPEr• k'es G Na (NOTE: FAAXIMUM FREE-FALL DEPTH IS 30) <br /> L'50;L rc-OR!NG 0„ARD AV0ZR GRO'-IT SPE'C;F!CATIONS: /2��a"� <br /> APPROX.BORING DEI''iTHISv � <br /> �' Ot,TG,..TRAFFIC SOX or D STOVE-FIPE <br /> — CJNDUC;TdR CASING PIR0P S "'S ED? (itiYES,11st spemficAons here): Y--� <br /> 'COMMENTS: <br /> -- ---- NOTE: OFFS1 T E BORINGS, REURE ACCESS OR ENCR AICHMENT PERMITS, <br /> �fCALL THE UNIT fv! I-t 3PECTOR 48 WORKING !:-OURS IN ,ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> i hereby--e;tify tha ` e prepar�;c� this applicFtlor; and. that the work will.be co,e in accordance with Sar Joaquin <br /> County Ordina es, Rule ars ations,and all applicable California State LOWS. <br /> signed x Ti,!er'Com�ar <br /> ''in'Ala,re <br /> UEPp;t TIENT US--E.N <br /> I <br /> SITE: MAP IN 0N.'T IN(FILE,AMDRESS: i <br /> WORK PLAIN DATED. — - - <br /> j,.�Fl;c:stion A:,o9pte`a E� � Area <br /> -_ . Datessued __ <br /> fsroui insNec+.z;.Ey-�--__� _ _ Date - -- Fina'Inspoloban By ; Data <br /> Dtr structton Ey Da' <br /> COMMENT$1 CONOMON s: <br /> ! AC COUNTING ONI-Y.- I I <br /> i A.,i,M � <br /> 1; PE CODES FEE If4FG j gMMOtlEv;REMITTED UHEC:K# Rfi�'D BY I DATln F?ERM17/SERVICE REQJzST# ; INVOICEi��3So--�-.1=-_ L" _ � ± C,� •8.02.. ---~ <br /> C-17 WC.--WAIVER C-�.7Utter of kjtfi orizaficn tc sisn permit <br /> Encroachment do+____ 9!27i0L <br /> I <br />