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SAN JOAQUIN COUNTY <br /> E --ONMENTAL HEALTH DEPARTMEWr <br /> SITE <br /> 6130wtst Main Street, Stockton, CA 95202-3029'-10' MITIGATION <br /> Tolophone., (209)468-3454 Fax.,(209)468-3433 WPb:mvw_ngqyprq 14 <br /> UNIT IV <br /> WELL PERMIT APPLICATION <br /> i� i 0 E'�'RVI <br /> ,T HE.fi.LT F1NON-REFUNDABLE NON-REFUNDABLE PERMIr EXPIRE1 YEAR FROM DATE <br /> PER INIH 110"EC ES <br /> Apohr.atmor is-,eret-y mane 10 S'sn Joe-qum Govntv for a Permit to vcmavuct andtor instal;Lite MM dMrlbed TtUs ambeshort Iis made u,cornpliant--.1mili San <br /> joequis k"O'.mly De4eopmsml fit'e (-,MapWr 9 1115,-3 and the St�Naros of San Jnaqwn CourAy Envmnmeentv f fealiti Depawn"i <br /> A Assessors <br /> Well Local xy o ctos$'$Ireel t 01 L 71p mpi It t(� <br /> bSd\4003 <br /> Property <br /> City ZIP 1 <br /> P4101v If <br /> 7, <br /> c1 r' Phone <br /> C-57 Contractor <br /> ConsuttanVSub Crtr i.WAdd(mj I 1�'�0 Mom <br /> Clry f..I <br /> $_Joe <br /> Gts coefdIamlot k y 1cm <br /> WORK TO BE PF-RFORMIM <br /> NE-WWELUEIORING ip-" H*tLIfRr)rk.lrnt4,Hr,IIr'iAU�-,Fr, OTH,R) DESTRUCTION fcpoosE TYPE EEL'W;: <br /> j 'N-01VER-13-1DRE DIAMETER <br /> -1 ----------- PW-=5SLlRE GROUT <br /> 0'OTHER �R­OROUT SPMFICATID <br /> NS <br /> - EXPLOSIVES 0r;:T0NATi'4r--,CARV <br /> COMMENT: <br /> 0 <br /> JUXL2 OF-WE L-L INSTALLATION TYPE a2_NSTRUC TION 8PE!PLFj4-ATtQjNS <br /> tMON 10441%t, E TEV t11A. Or BOPLHOLL Ll 4101 tIPI,FCA,;Mr4S n'VlUlr�LEVEL 1AEU CAS!tlo LT A <br /> Q Ex 0 A'R I i AV til e R P N V Fitj CAWN TYPE OF CAtlNG ri SI FE L'br,!-""(-- 0 ()T'4Cr" <br /> I VLs-tri AR FxTtj or f.,RCjVr$.E AL IE US <br /> t)r ,. TREWE TYPE 10 L <br /> tj AM SrAAL;E�010NE U PLI-H I-0!NT tGPOR CPT!___ G'IOQT',LAL PV�.1,PFD ccs 0 to (NOTE,MAXIMUM FREE-FALL DEPTH IS 30) <br /> a SOIL mmm-'- <br /> 0 0T.1 P Fj cmic;l AjPz1W,)Y, <br /> _'.- --IL- tECVOLA-1:0 I FVFPfC 030K OR RSTO'�'E PI <br /> I Amekvo)f r,v <br /> COMMEN TS <br /> NOTE: OFFSITE BORING$ REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REOUIRED FOR INSMTION9 <br /> I hereby certify that I 11-tavo prepared this application and that the work will be Bono I accordance with San joaqutn COUnty 001nam5,Rules and <br /> Ragulatlons,aild all applicable California Law*. <br /> Em <br /> DEPARTMENT USE ONLY <br /> D -A <br /> w I.A� <br /> 1 E r,4AF-IN uNi, I Ff��E Arj�. ZE5 <br /> -5 <br /> WORK F1 AN DATED m-r- 2-.0-1xi <br /> D AREA <br /> APPLICATinN XPTFT�Ry <br /> G'O"T'NSP'C""jN'Y -­- ---JJ­­­-- FlNAL INSPECTM)N BY DAI-E <br /> DESIRUC lION' OATS Cµ _ l ___ <br /> COMMENYSICONDITIONS <br /> ACCOUNTING ONLY AID it PAC 9 <br /> FSE.CODES FEE INFO 1 AMT REMITTED CHECK ir RECVID By DATE PrRmirs-EfIVICE N INVOICE <br /> 0 - C> -Lo'l y0 3SR# 603o8C-S-7 Vill-, -',AWAIVFR T w C57 LFTTFR'OF AUTH477MON-73 51GtJ7±77 T t-:NCRr)A-.GM4ENr T 0C)C <br /> 171-11 M t.L PE R.Vi r Ax P <br /> 3sd3 <br />