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?. :eu:• SAN JOAQUIN COUNTY Copy <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 SITE <br /> A Telephone:(200)46&3454 Fax:(209)468-3433 Web:wWW s1aGv DrdMITIGATION <br /> $ehd UNIT IV <br /> WELL PERMIT APPLICATION L�y1 ( <br /> NQN-RA152NDAHLE PEWjTEXFM$1 YEAR FIJQM DATE ISSUED ! /-t7T/V ✓[fl <br /> A0WCjOgn 1s hembYmada to San Joaquin County fora permit to constrict and/or Install the work desalted. This appficaBaT LS made hcanWlattce Witt San <br /> Jaaghtn County De'v/elopment Title,chapter 9-1115,9 and the Star rds3t San Joquin County Environmental Health DepartmenE <br /> WOO Laoagon/11 5 rocs Street DOUG(}$ ,2d( Assesso(5- <br /> Proparty Zta 'eS —5 _—_- - :Ity ftiC mss Zip �.t�f7 Parcel#0? <br /> UWrieT a Address 77oo`p/�p�r �/elrn b�, City SaGtM.c.� Zip ST?4 Phone It 9/6-SQ6•R$00 <br /> OS7 C'oneactoT 7$'G Address/l3Sd/ ,,,'Pp,"•—�J-S�•,�[yP;:- CRY �ZZirf-E�Llcx 7eES28 Pnaa <br /> CottanpaMiSue Cnv 2G9'd/ S Address / / CItY V ✓: t Uox Pnana,$ Q mie <br /> - <br /> (3I86ourdlnat6s:X 3g•oI0 ,Y -IZI. yyT Range Saatlon <br /> gEPBtFERtyEp;,$ <br /> BORINGA ( ���� PUNGK W{ND.AIfiEiF•GTNER') ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> D OVER-BORE DIAMETER_ <br /> D'OTHER 13 PRESSURE GROUT <br /> GROUT SPECIFICATIU <br /> 0 EXPLOSIVES DEYONATIN&CARD S� <br /> COMMENTS <br /> - •.L INBTALLATTOTF TYPE CONEM101"SPECIFICATIONS <br /> MoNrF RWC' 11 HOLLOW STEM Uk OF SOREHOLE� 0 MULTIPLE GSINGS 0 MULT4LEVEL WELLCASING OIA_ <br /> ^QE,rR�TP--A--CNON ❑AIR HAMMERORvEN CASING THICKNESS TYPE OF CASING.-0 STEEL d PVC O OTHER _ <br /> WTD Q MUD ROTARY DEPTH OF GROUT SEAL�TREMIE TYPE TO BE USED 0 AUGERS[3 HOSE <br /> DAIRSPARGEOOZONE EI"OSH POINT(GP OR CPT)_GROUT SEAL PUMPED:❑Yat ❑ (NOTE:MAXIMUM FREE-FALL DEPT"IS 10') <br /> DWILRORING 0HAND AUGER GROUT SPEGFICATIONS ,"9 - CSixEN'T'� <br /> QATHEN:. ❑OTHE2 APPROX.BORING DEPTH r I []BOLTED TRAFFIC BOX DR O SFOVE PIPE <br /> COMMENTS. GJ R. p Ptes.lsr, h - <br /> _NM' OFFS"BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PER TS <br /> 48.WORKINQ HtJUR NOlIQxKRWIKLUINSpECWKS \ <br /> I.hfrarb 01114 that I ha prepared this apppcatldn and"Un the Work W'11 be dere 1 accordance With San•foe in GJ <br /> . Re9Jd6{bM,and i kAlife CaR/orRla Lalvs. W UrmTy�U.�d(Titaa`cesJ�Rales and <br /> Sf07ad J TIVe/Compohy <br /> —Date,S`Y-Zo <br /> DEPARTML'NT USE ONLY 2 <br /> 5T MAP W UNIT IV FOX,.ADDRESS: r r /—o+ �,pAV- <br /> WORKPLANDATED: <br /> APPDC"ON ACCEPTED BY DATE 1 d I a Amt Vf1 ' <br /> � Ta�LSPE£TKST•iBY' FINAL INSPECTION BY DATE -5'7 /O <br /> UtMucTION INSPECTION BY DATE <br /> CONMEW&CONDrtIONS: <br /> ACCOUNTH&ONLY- AID'ii FACA <br /> PF Can" FEVINFO AMT REMITTED CHECK# RECH'D BY GATE PE}iM1TJSERMCE# INVOICE <br /> -2 SS 305.3•10 ID <br /> O-SY we V -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT DOC <br /> PJ'1B'QB&Ot fOT211/tla L <br />