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uti/L1/0L YHl 1L lu rA.& 1 010 001 u4uu -Z1A%11+1M9u.iriU �� .+..��+• � • ' ++•+ ' <br /> 06f21f2892 88, 20 2094683433 <br /> FIFTH FLOOR I PAGE B4 V <br /> bw� 1jr31 ro <br /> �MU1-[� <br /> WELL PERMIT APPLICATION FO M SITE <br /> � I �m�aTloN <br /> SAN <br /> dQAQU1N COUNTY PUBLIC HEALTH SERVICES [,/NIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PH5-EHo� <br /> 304 E. Weber, Third Floor, Stockton, CA., 96202 <br /> (209) 468.3449 <br /> 11QN-REEL! DA PERMIT PIRES 7 YEAR FROFA Q aUED rcation�s made In compEl$nce with San <br />,application Is hereby triode to San Joaquin County for a parmit to construct and/or mmil the work described This app <br /> Joaquin County D valopment T(te,Gnapter 9.1115 3 and the Standards at San Joaquin Courcy Rrblrc tieahh ftM--s,Envrronman� hgplvle�n <br /> or r 9f F-"-�.�wx-- 6� CIAF��IP Parte[# <br /> WELL 4acmtla S' r f ��"��- Cross Stfaea <br /> ZSno' bra ad✓ IP� rPhonefP 3�a <br /> PROPERTY Owns- �•� ddress! '�- Ctiiy <br /> C-67 COntmclor <br /> dre5s <br /> Consultiutt l bub Gonw,.wr dress <br /> GIS Cioordinataa' <br /> y TownshEp_ Range Section <br /> wa_RK TO BE PERFORuItr_n. I oESTRUCTION(choose type below) <br />)(NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,H"D-AUGEfa,OTHER-) 0 �OVER-SORE <br /> a SOIL BORING 0 []PRESSURE GFLOVT <br /> � ���'�� <br /> 'Other ELL Grout SpedTications <br /> COMME WS. <br /> �'r1[Ii�S � <br /> TYPE OF W IFI9T& Tlo� CrJHSTRUCTICN SPEC¢L�_ ' <br /> MULTIPLE:CASINGSP I1 YES �10 WELL CASING QIA. <br /> Yn,, & <br /> pN[rpAING CLOW STEM DIA OF 130REHOl� OTHER <br />/�_ CTION p AIR HAMMER/DRIVEN CASING THICKNESS�TYPE OF CASING: 13 STEEL �'PVC 11 <br /> R ❑MUD ROTARY DEPTH OF ISROLIT SEAL 't- T Rp_mti"TYPE TO 13E USED 11 AUGERS U HOSE <br /> AIR SPARGE PUSH POINT GROUT SEAL PUMPED �es 13 N. (NOMI=' MAXIMUM FREE-FALL DEPTH IS 90') <br /> Q SOIL BORING n HAND AUGER 101F 000— <br /> CF[OUT SpEC11"ICATfoNS 70 �4G E&GLTE3GTR�IFFIC 60X or 1]STOVEPIPE <br /> (] <br /> OTHER _[1 <br /> OTHER_- APPROX BORING DEP <br /> CONDUCTOR CASING PFIOPOSED9 /V� (it Nts,fist 5p4ciliradons here) <br /> I,Y s f y Sg- <br /> NOTE; OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS 1N ADVANCE 1=0R ALL REQUIRED INSPECTIONS. <br /> I hereby cer#iffy that I have prepared this application and that thO work will be clone jr,accordance with Stn Joaquin <br /> County Ordinahceks, ales and RegulatlOns, and all applicable Callfamia State Law--- <br /> S I g n a d <br /> aw---SIgnad x 71t1BIComparty <br /> PM1 Name_ DEPAMMENUSE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: a <br /> WORK PLAN DATED: <br /> Pate ISSUod <br /> Applieatlon Accepted ey pale <br /> Grout Inspection By <br /> Darts_ Fatal Irttipechon BY <br /> Desauction Imspection Da[e <br /> COMIAENTs I CON131`11CI49, <br /> OUNTING ONLY AID# cArr <br /> pE GOpE3 FEE IFjFo p�Ql]B4T f�IENII>E"fEp CHECK S RI=C'G BY DATE PERmi-r!SERVIOE ReouEBY S WVCHGE <br /> 3S—oi .n� s�.6zSsSs I.Jc 16 120 oz gR 3 c7 <br /> C-57 WC -WAZI/ER— <br /> C-57 Letter of Authorization to sign Perrnit Encroachment doc 9��7�fl0 <br />