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k° 4M1 SAN JOAQUIN COUNTY � �`-J MD <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MfrlGrATION <br /> Telephone:(209)4683 w454 Fox:(209)468-3433 Web:wwsiclbv.D49hd UNIT tv <br /> r WELL PERMIT APPLICATION <br /> NQN-REFI INDAB E PERMIT EXPIRES 1 YEAR FROM DATE kSUED <br /> APWICefaatfs;henTliY madabSan JoaqulnCounryfor a pamHt t3 wdb <br /> nstructanr Inswork Install She da3Cnbed. ThIS appllaaotld coln <br /> It made In pllanse with San <br /> Jtiastu(n County DaYelopmentTltle,chapter 9-1175.3 and Sle9lenderds of San Joaquin County Envlronmental Health Department <br /> c;Fr A. E Aseeswes <br /> We11A.edatlon % coir -la��r Cross street Q .n.»;ic Ne/! De. city Ciivek-/'a,.. ap 95207 PXca1A047-yi©- 7 <br /> PToile.-if.-ms9. <br /> partytt� n e+-des LTrO <br /> ZAddress $7fI zi weO/ii City 7Jp?S-A07 PMma/i -a/7 8203 <br /> c-s7 ColaTactor ITG-h ;4M Ok Address y/3m fll ;g -AIAA Amzclry 4?1" vp-Y,CTy��n 7r✓�P10 <br /> CensatlanUSub Fairs Add.e '?go 4A r1x11x4r(071 City '�A7a"Yy,y& LIC# Whone Sha-6s'L-4Seb rA <br /> (As Coordinates;x t> .Y —I ,I.3Z3 .Ya ship Ranee Section <br /> =YO AE PERFORMED: <br /> w5YVLLJ9.OWNG(CPT,GEOPROBE HAND-AUGER,HANDUGER,OTHER•) ElDESTRUCTION(CHOOSE TYPE BELOW) <br /> I]'SOIL BpAiNG%_2 (SC-�-/ 96-?.) Ej QVEK-BORE DIAMETER <br /> ©WELL S ❑PRESSURE GROUT <br /> []*&HETR GROUT$PECJFICATIONS <br /> El EXPLOSIVE$GETONATINa CARD <br /> COMMENTS: <br /> Twp OS WALL IN5TA(J:ATION TYPE CONSTRUCTION SPECIFICATIONS <br /> t3 MONITORING D HOLLOW STEM DV OFBOREHOLE y' ❑MULTIPLE CASINGS❑MULT LEVEL WELLCASINGDIAr_ <br /> [3 EXTRACTION CI AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASINfk❑STEEL[3 PVC 0 OTHER <br /> (i2pAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED El AUGERS❑HOSE <br /> ❑AIR SPARGFJOZONE tlla•PUSH POINT(IIP OR CPT)_GROUT SEAL PUMPED.❑Ym O No(NOTE:MAXIMUM RREA-FALL DEPTH IS M <br /> ❑SOILSORINO ❑HANDAUGER GROUT SPECIFICATIONS <br /> []OTTNER^. OOTHER: APPROX.BORING DEPTH �� ❑BOLTEOTRAFFlCSOX OR LISTOVEPIPE <br /> �f�tK,OR MOPR D_ If YfS,IY Yt { <br /> COMMENTS! _-,(A.c✓ Grr a4n....nlSawc cam . .., s-• r� r d. ..wa T.bl, <br /> NOTE: OFFSOFTE BOR tS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 4B WORKIN(S URS:NOTICE REQUIRED FOR INSPECTIONS <br /> I hdreb�ycceei01trya A haw prspared this appt{ratlon and that the workaMl be dans I a ccoldaneavAlh-San JoaglAn CVuRtyOrdinanaes,RuARrund <br /> rwil'' Sir ant! la cat r+lla Law$. <br /> SV-d Tidnrcampany (C,,-'tt (stela rrfT�/f/'Lfr#/1fS _ <br /> east Nafnp. ,Crt,•�. _l��fi/',a.,� , Pl>. Data S Y-/O <br /> DEPARTMENT60 <br /> VrE MA.F IPI UNfT IV FH.E.ADDRESS: D <br /> vN[fRK FIfiFF EIATBp: / <br /> Z. / <br /> APPL1CATy3NACCEPTEDBY DATE E ��0�i0 AREA w` /1 <br /> GTtO(!T IPf9PECT10N BY FINAL INSPECTION BY DATE ,I��iO I\���\\- <br /> DE,4TRUCnON INWECTION BV DATE Vc�r <br /> GL"GOLINPIPFra Y: MON FAC# <br /> pE.L'lIdA4 FEEMIFD AWr REMITTED CHECK M RECW SY DATA PttRT11Tf9ERVICEi INV4MCE <br /> 0 5 <br /> _ V •WAaVER C57 OF AUTHORIZE TO SI(6N PERMff V ENG M li r DOC <br /> EftD''CSOS t4'IBNB WELL PERT <br />