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r <br /> " - 9 -, <br /> _ v-- - - SAN JOAQUIN COUNTY �� �- <br /> " L.IFNVIRONMENTAL HEALTH DEPARTMENT L� <br /> SITE <br /> �,�, 600 East Main Street, Stockton,CA 95202-3029 MITIGATION <br /> UL ) hone_(209)468-3449 Fax:(209)468-3433 Web:www.si4ov.or_q/&A UNIT IV <br /> ENMRC.IW�1i 111d Ti ff;'LTH WELL PERMIT APPLICATION <br /> '3� EFUNDARLE PER7uil,EXPIRES 1 YEAR FRAM RATE ISSUED <br /> 4301calmn is harehy rmdle to San Joaquin Cex q for a per Tm to caruuud androrwnsal the work described. This appicaiion*made in <br /> comp4a>ce wiilh San <br /> !aar Cocatty DeveVoprr�r4 Tdle, 9 11 X5.3 Mrd YIe S>antlarCs of San J�aT..•"G Ermrarnental Health Department <br /> (-'�tr e/vim N // <br /> Wett Lnratlon{G�°?� �C'""�,~Crass Strmt ..J a .«, CRy 7L+c fu.:Ztp <br /> Prop" 4 -- -- <br /> owner F f-4 Lr.r✓-5} .ter-.�Addruss �•7-7_( !-�c•.L•.✓ i�r f !N/�� j 'Phones to <br /> _7 City c Lp r o� 7 7 <br /> C-iT Contractor�` ` (? I t"5 Address S c. 1!-o.,Z ��. ,• City}�, 4.--{�_ �—tJc� 71or>e Z 1. - c'f c:c� <br /> Cor*x*m Hub Cntr — A.ddrass - CIry — _.. Lic s. Phorle — <br /> CWSCoordinales:X — Y Tovrtdip — Range SedQ <br /> WORK To SE P ERFORXII <br /> ❑NEW WeLLIBORING(CP7.GE:amcaE.RYOROaUNCR HANDfUr.;M OTHERn Q DESTRUCTION(CHOOSE TYPE MLOV6 <br /> CI 501LVVE]LOMNG#_ 13- l (3- �— `_�'1_._.� ❑OVER4K)RE DIAMETER <br /> O'OTHER ❑PRESSURE GROUT <br /> r _._..-.__.. GROUT SPECIFICATIONS <br /> TYPE OF VWLL MTA1.LATION TYPE ON SPECT <br /> I_I MONrTORING 0 HOLLOW STFAJ OUt OF BORR4DL " ❑ Lp p� TIPLE CASINGS O MULT4EVEL VVE L OA,SING flfa- <br /> 0 EXTRACTION ❑AIR HAMMOMRP&N CA.AWx;TI4CrQIESS �v 4— TYPE OF CASNG El STiML Q PVC❑ OTHER `1iL <br /> r <br /> C7 VAPOR 1]MIA}ROTARY DEPTH OF GROUT SEAL TREME TYPE TO K U,---P❑AWGC1`5 Q HOS <br /> n AIR SPARGEKJZONE lt"SH POW(GP OR CYTS_._GRCWT SEAL FLWPM:G{Yns (NOTE:OTE:MA)UMUY FREE-F 3(r)SOnLRI <br /> 6ONG '9,4MDAUGER GROUISPLOnCATIOHS-cj?j6f2jjf Ge..-� T <br /> n DTRm C OTHER: APPROX SO-NG DEPTH HD 171SOLTEOTRAFFIC 6OR sTotir rIPE.CC u 7ZoRCASre <br /> WMMENTS fdr¢s.t : <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS \ y <br /> 4a WORMAIG HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> i <br /> 1 hereby codify that I have prepared ' Ia appllca*m d that the wwk wIIT no dare I atcovgarxo,with San Jo�agUin Counly Ordinances,Rules and <br /> Regulations,and all b rni�Laws yt�f `[�j�- / `{ <br /> &9� �nq� Ti0&Consrarry f ya '_' N Vm <br /> Print Narne C •1`"f Dale Ct 11 <br /> DEPARTMENT USEONLYZQ S4 <br /> SITE MAP IM UNfT IV FILE,AT)DRESS_ <br /> WORN PLAN OAT—t:[), <br /> APP JCATIGN ACCFPT'ED Ery DA�Fl / �Z —�� AREA <br /> GROUT IW,SAFCT(CDN EY RNAL INSPECTION BY ✓ DA 'J I <br /> DESTRUCTION RJSPECTIDN BY /i DATE <br /> C01MAI NTWCONDMONS <br /> ACCOUNTING ONLY: AID f FAC# <br /> ;P1EOOE9 FIwE INFO AMT RZUMTD CHECK II RECVD BY DATE PERt1 ISERVICE# twotcE <br /> sq',- 63 Z 7•Z -aZ <br /> C- V4C -WAIVER CW LE fTER OF AUTj lMZATION TIO SIGN PERMIT ENCROACIiMEW DOC <br /> erm 7aol WWU PEFW T APP <br />