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• <br /> �eul SAN JOAQUIN COUNTY COPY <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Telephone:(209)468-3454 Fax:(209)468-3433 Web:www.s1Qov.OrWehd UNff N <br /> WELL PERMIT APPLICATION <br /> NQ%-REFUHDA$LF PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Applidaedn Is helebyriade to San Joaquin County for a pernR to oonstruct andlor Install the Mork desmilbed. This appricetlan is made in con nonce vAth San <br /> Joaquin county Development Title,chapter 94 115-3 and thq•Standards of San Joaquin County Environmental Health Oepalhoent �aswe's <br /> �yt� {rac.F:< 9+E <br /> Well Lacadon Cross Street City, �l/ae/L a.+ Lp <{ _ Pare ssoWs -w4.7 j <br /> Property L[trCe�- CT9 {. <br /> OWrlar ♦ r - t4: .Address ?7 r—L'NCO/a CGa+tCJ` Citys/oetr— Tip s-201 phon�ttt44-478�9s'�rf <br /> C47 Contractor )- fi+ I!;, Address /!Ja O 'el Pa./c t eat City&" ZIp IS 74Z Uclt 70 Phone <br /> ss ra a <br /> ! Adrea/fvA / 1tPhone sueCdnstdTantrsub Cv* / e(A / <br /> GISCaordneles:X 3 w <br /> w •> '2.4sto <br /> '37- Range Section <br /> W�Q�RK„TU dE PPjlRDaMED: <br /> d{{'E1N. (riRINDjCPT G�OPROBE.tl1'DROPU H,HANRAUGER OTHER-) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> OlLBORiNG# /SFi•,�, Sb-y.S6{-/ Cr'7I ❑OVER-BORE DIAMETER O <br /> f4YE11R ❑PRESSURE GROUT <br /> C7 wQTHER GROUT SP€GIFICAT1698 <br /> ❑EXPLOSIVES DETONATIN CAR1 O <br /> QOMMENTB: [VV, <br /> WP-�Q��yF�VJEti. INSTALLATION TYPE CONSTROCTWN SPECIFICATIONS t� <br /> fl MONITOME; 0 HOLLOW STEM DIA.OFSOREHOLE ! E ❑MULTIPLE CASINGS O MU1.FI-LEVEE WaL CASING DIA_ C <br /> 1 <br /> u.f9f-TRAfiION ❑p1R ki4MMER/ORIVEN CASING TMR',IOIESS TYPEDF CASING:0STEEL 0PVG C] OTHER <br /> f>,44pOR O MUD ROTARY DEPTH OF GROUT SEAL TREmrE TYPE TO BE USED O AUGERS O HOSE <br /> [3,Aw SPARG6RJ20NE E'FUSH POINT(GP ORGPT)_GROUT SEAL PUMPED:O Yba O No(NOTE:MAXIMUM EREE4ALL OEM IS 30) <br /> El SOIL eORNG O HAND AUGER GROUT SPEGROAT)ON5 <br /> O.OTHER, [I OTHER APPROX.BORING DEFTH ZDV ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> NDUCIORC 0 ( TEe,lbr <br /> COMENTS:rte -- . <br /> NOTE! OFFSITE BORINGS REQUIRE ACCESS AGREEMENT ON ENCROACHMENT PERMITS <br /> 48 WOR NG HOURS NOTICE REOtARIED 06R INSIP9VIMS <br /> 1 toreby carlRy Nat I he va preparod this application and that the work MMR be done 1 accordance with San Joaquin Cowdy(hdimartees,Rides and <br /> lits"Moom,and SIT�a C, Nor la Laws. �y <br /> Signed Tma/CornPam cle'm lea/OAY� /iTxCcr�ffl/S' <br /> > - ! <br /> srndtNama E•..+ e. Dum <br /> PRT ,It 2-/-66 <br /> WM R WP INUIT WILE,E,ADDRESS: <br /> VVOR c PtAN:DATED: O dKA <br /> APpUCA'fTON ACCEPTED SY DATE lfdf/0 AREA <br /> GROUT WSPEOTmay FINAL INSPECTION BY DATE <br /> OESTRUETION RC 1EMON BY DATE <br /> C9MMENT3lGQNOTTIQNSt ^ <br /> If71NO OPa.Y: AID# FAC 0 l \ <br /> PE LADES <br /> 1XINFO ALIT REMITTED CHECKS RECY'D BY DATff PERtAI'C18ERME A INVOKE s <br /> C41-40—F lf -WAVER C57 LETTER AIJTHORt7ATION TO SIGN PERMIT ftF ENCROAtIiJdEN7 DOC AZLd <br /> ` <br /> EH9>'S•.g17ryffig9 W19LL FEEtmi 0. <br />