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ize e5 '2dlji ii Ida 2094683433 FIFTH FLOOR F`AGE 01 <br /> 1VELL PERMIT APPLICATION F'ORIlfii SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-F-140 UNIT IV <br /> r 304 E.Weber, Third Floor, Stockton, CA., 96202 <br /> l x �= f (209) 46"449 <br /> NON-REFUNDAS FtAfIIT EYPIFIES 9 YE dM VATS 1S.a"UE <br /> Applmzitton is hereby made to San Jo8qujn CwntyW a perm tto aonstructandfor install thew)LI*deswbed. This apphcabon is made in WmphOnce w,tn szr- <br /> JOzqujn County Development Title,Ghapwr9-1115 8 and the Standards of Sad Joaquin County PuUtic Health ServlteS,EV01;nmEntal Health Division <br /> -7 Assessor's <br /> WELL Location_ !01 W r`!�f�Ii a w G `Crass stt'eet ` City rl�v ap��Parrel#_ �_t�t`o—� Q 'Q 7 <br /> PF0PERTY0v,ner T S +G COr pC arE pddrsss_ Sic I3d City J"l eBZip 6 Phone# <br /> Cld36.32 <br /> G-S7 Conir2r C G4ic <br /> Qr a I�1gA carers ', I� Cliv <br /> Cormwutnt l Sub Contractor Yid t 1yI V} dress-7-3 ,. r.5 �9 Clay c�Lids �I prio,� 15 I Q <br /> C[5 Coarcllnatss X -37C1,15--T, Y _loLId a[r __ .Township a JV }cense E7/Ze Section <br /> VVCFZK`r4_EE PERFORMED <br /> XNEW YVELL/BORING(OPT,SEOPROBE,"YOROPUNCH.HAND-AUGER,OTHIIN-) p 01=STRUCTION(choasa type bolow) <br /> Ei SOIL BORI14M 4 n OVER-BORE <br /> -KWELL#`"_ 10 _ d PRESSURE GR01 T <br /> -aLher GROUT SPEClIFICA710N <br /> COMILIENTS <br /> I <br /> TYPE ofIIVE INSTALLATM 7YF6 CONSTRUCTION P C F QATt0WS <br /> 11 MON170PING XHOLLOW$TEM DIA.QF BOREHOLE—'P—'f MULTIPLE CASINGS' 1]YES *0 WELL CASING PIA 1 ,f <br /> 0 EXTRACTION 11 AIR HAMMER/DRIVF.N CASING THICKNE85-&QLffjj—_TYPE OF CASING. I7 STEEL kvc (]orhER <br /> 0 VA POR 11 MUD ROTARY DEPTH OF GROUT SE=AL '- SO'. 7REl44IE TYPE TO Be USED, AUG>=RS p-ios= <br /> X. RSPARGE nPUSt• POINT GFt0UTSEALPUIViPE0 Yes No NOTE- MAXIMUM FRF-F=-PALLDEF'TH IS 30 <br /> L BORING [I HAND RUGER GROUT 5PEGIFIC.ATION-_. A CA! J �,y <br /> Er n OTHER APPROX BORING DEiFr i.3g'w111Y BOLTED TRAFFIC BOX or 0 SiaVE PIPE <br /> CON dUCTOR�CASING PRpppSBQ?uO (it YE5,hat sperafi catlons here) <br /> coMMEN7S Ick :� �gr� I.v_�lls �J' .� "! ►I al Gd+,�+PL>rr}�`rivti t✓► ." r4 }s <br /> NOTE. OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby certify that I have prepared this application and that the work will he done in saoohdance with Satz Joac]utn <br /> County Ordlrlanoes,State Laws, and Rules and Regulations of the Sart Joaquin C*unty <br /> CALL THE UNIT lV INSPECTOR 48 WORKINGS HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS <br /> I <br /> Signed x_- .. T2tle/Company 5 . f4(T Ice ; �` J, r,r, c f (�tS�1✓� u,s <br /> Pant Name _ U ate I i ld 1 <br /> SITE MAP IN UNIT IV FILE ADDRESS /WORK PLAN DATED -1-70! `9VAx-k <br /> ARTMEFTf USE orlt. <br /> ajplaabon Accepted 8y <br /> Gate JSsttt3 Area <br /> Groul Inspecton By Pate Final Inspection By E7a[e <br /> 17e5Eructzon inspection Sy Data <br /> COMMENTZ I CONDITIONS <br /> ACCOUNTING ONLY AID# <br /> + PE CODFS 54E IMI=O AMOUNT RIEMITTED CiiFnK RE=6Y DATE PEMITl519RACI=It�4UESTV INVOICE <br /> 7 WC/WAIVFR C-57 Letter of ALlthartxation to sign permit Encroachtnent doh_ 7/17/00 <br />