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i <br /> WELPERMIT APPLICATION °FORM . SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 96202 <br /> (209)468.3448 <br /> NOW4WFUMMLEP DATE IM <br /> �ran eaft .12 hsmby made to SJoaquin county tare pemin to mestrurt and/or k+st,l Inc want de%AW. ThD appltcaGon Is nada In carrQNatroe with$an <br /> Joaquin counq►Developrnent Title,Ctaptor im i S.S and the Standards of San Jamdn Carat r Puble HeaM Servfom ghvk nmwftll Health dMdm <br /> uuFr N Dr�d� Crr sheet Lair G�j► � ��� <br /> �— <br /> p y Owner aedea 250 W. Celt'mad CltyEp ,Phone# – <br /> c4r voraracW �� _Addrese � '�•• PIVO na 5 �/455-i�I12. <br /> Consultaint/Sub Contra �irn 34�D E. St. pty B im„_ „hone# 5Ei2/9BB--2756 <br /> GIS Cm�X Y Township TIN Ra++ge ? <br /> WORKTO8E Q <br /> 13 NEW WELL lBORING(CF-T,G±OPRCBEiYDROPUNCHHAD-IWGROTKER') PLDSSRimlo ; <br /> W BORIN�# <br /> � <br /> PJ=L7 �YUG <br /> L <br /> Gout spew a Hite �y <br /> COMMENTS: yY. a <br /> nm9 OPyIlE'l.L ANSTALLAYIOH'1YPe CONStRUCTMNAmmighmm <br /> t3 MULTIPLE CASINGS? YE5 7d NO WELL CASING D �, <br /> iMt7NtTOiIta i�HOLIAW STEM OIA.OFt30REiIOI. .�_ <br /> d EXTRACTION Il AIR HAMMERIDRTVEN CASING THKMEt3S 3116' TYPE OF CASING: a STEEL )I PVC 0 OTHER: <br /> a VAPOR I?MUD ROTARY 0EPTH OF GROUT SEAL �7 TREMIE TYPE To 8E USED: (j AUGER$ p HOSE <br /> p AIR SPARGE p PUSH POINT GROUT WAL PUMPED: p Yea 0No {NOTE:NiAX1MUM FRET-FALL DEPTH 19 30') <br /> ti SOIL BORING p HMb AUGER GROUT SPWFrCAT1Ot+ls: W11 G Ut -'mrbavt- <br /> on-toR: APPROX sORING DEPTH f f or.TW TRWIC BOX or.1 p wove I'Me <br /> Cor4ouCTOR CASING PROPOGED? _E It VIM Uet XmffiQ&00m harey: <br /> roOM t11ENTS: sp=ficatigns above aeswibe the to of wells to be raged and al s rimed by poesyye . <br /> (VOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> I hereby certify that I have prepared this applicaUan and than the vvork will be done in accordance with San,losquin <br /> County Ordinances,RUIeVind Regulations,and all applicable California State LaWs. <br /> sed >�R. t..Ce 4 Ria <br /> Posit Name Date 17-��-4 <br /> D P�MENT USE OIrI�Y <br /> SITE MAP IN UNIT IV FILE,ADDRESS:,__„_ <br /> WORK PLAN DATED: <br /> ApMlcadon A=epted ft_ _... . _ _0318 0318 ea <br /> Omit Inmet6m By nal Inspedon Ely <br /> besEucdon Z 20 Q 1 <br /> COMM15M l CONDMODIS: <br /> ACCDIJNTI!*tt3 AM <br /> A <br /> PI:CODES IN INFO AMOUNT REMWMD CHECK a RECD BY DATE PERIMII'I SERVICE REQUE$r a ardOICE <br /> Sg# Ooz? 2? <br /> C-57 Wi -WAIVER C-57 Letter of Authorization to sign permit Encroachment doe 9/7-7/00 <br />