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11/20/2171J17 lb:4b ly1bbJbnb11 1-;AbUAVt 1JKJ.LLINIU 1NU l AUL 1jj <br />RIIjINAL <br />WELL PERMIT APPLICATION FORM SITE <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br />ENVIRONMENTAL HEALTH DIMtON (PHS-EHD) UNfT Iv. <br />304 E_ Weber, Third Floor, Stockton, CA., 95202 Q <br />(209) 468.3449 CJ ' <br />Igo :mUdm" PtElallrr ffxrt I Yam �IeoM T! ••, �, � <br />Ap{rFoallon to n.r eby,nada x� ®.,, b.qW„ Ccurtb /vr a p.mic b oor�ovp w+eror hueall fIa <br />WOO Omftad. This appluAm is vlalba In compl.no vAl% Sin <br />Joaquin County Dryslopment TIk, Chepbr SO I I 5.3@pd the 8TO ofl s4m JoqWn npRelic FMa1h aw+1oN, Mvkorrnt>r�lal HaR� phyloR <br />WELL L4c■eon�% �C7lh 13 t V!✓�C ow )sweat 3+° l t Lo F L P o %533v <br />PRQPER71' W1-]-- Addrwa L rLr)S I UVv -ArW- c M & ,>P no /S ones l O7 �� Z SU0 <br />C47 Cnntmc(D FfP,11Y_ jitNl_J//r��,C: - i <br />Consultarn i Sub CrntratADr T (17PP Add►aaa Uol1_ _��I�af � ' �b LXX <br />f>➢18 Coorelrvstat: x! __� T , Tw�r►tHp Rance <br />womis TO at <br />IL <br />WsIEW WELL I DORM 4 CPT, aeoM 1E1E, KyoRoTLRVCN, HAND.AI?GM OTHER1 babW) <br />G 0 001011-90F1119 <br />'Otirr aL�,.•�= 8 O�but 90aeMiCslbnac O PPMOLIRE UT <br />COMMENTS: <br />=C OF WE <br />'XMONrroFeNl3 <br />INU&6AmQNj= <br />WiMLOW URN <br />6 EXTRACTION <br />p AIR HAP"WORIVEN <br />G VAPOR <br />0 MUD RCTARY <br />0 AIR SPARGE <br />u RUSH "KT <br />0 801E BORING <br />11 HAND AUGER <br />a OTHER. <br />d <br />l.Xlsld 11 <br />OIA OF WR6MOL! muor a CA$INOS'r d YES .�lO W U CAM QI <br />CAGING TMICI(►i$S CMi 0 TYPE or CA NIM 13 mm `0:! -VC o OTS„ <br />DEPTH OF GROUT TFIl:ME r0% TO a[ USED- . I)AU"Aa 0 NOW <br />GROUT SEAL PUJMM! 0 Yoe 'A$10 (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />GRO 1r SPECIFICAn 141441 <br />APPROX BORING DEPT -�40LTW TRAFPIC WX ar 13 STOVE PIPE <br />CONDUICTOR CA8lNa PROP'O8ED7 WO 11/YU.Ilrtaped5=ftW <br />'COMMMTa: <br />NOTE; OFF3ITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br />CALL THE UNIT IV INSPECTOR 48 WOR19NO HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />I hereby certify that I have prepared this application and that the work will be done In accordance with San Joaquin <br />County Ordlna ulas and Rapulatians, end all applicable Calffornis Stais Laws. / <br />SWWrrd _/ TpalCernpony s ,� , rw-Q G 9r / �li rte <br />Prinl Nams___ -e—rg_ QP M a ✓A Dab z ' 7-6 <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: i <br />400000k- Ac—pbd ISN lr m Cl <br />'7 <br />3rout Inspecion By Oak— final wapeaaon Vy .� <br />)*sVU W Inspac don Vy Data <br />:00MENT3/CONDIfl0043: 5,77,77,7777? -7-7-7 VC--!' _ l " <br />ACCOUNTING ONLY: ADM <br />PC CODES <br />FEE INFO AMOUNT RBUIrr78D CHECK t <br />F&C'0 BY <br />DATE R <br />Yr11OIC[ <br />- <br />2G <br />2 j <br />C-57_ _ WC -WAIVED C-57 Letter of Autherizeion to sign pernlit—.�--FperoachltunT doC Iriciiw <br />rkN <br />C <br />