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04123/.032 1::46 7i:5 "3133 <br />F:. _z •? : <br />WELL PERMIT APPLICATION FORMA SITE <br />SAN JOAQUIN COUNTY MITIGATION <br />ENVIRONMENTAL HEALTH DEPAF111MENT (EHD) UNIT IV <br />n 304 E. Weber, Third Floor, Stocktgw. CA., 95202 f <br />SSS (209) 488-344S' O to <br />NQK-REFUNQABUE PERMIT jYPIRE8 1 Y6A t��R�M DATE IS$UF�D <br />crF:lc..ator s heroc • mace'.o San !Jacuin Ccuisry for a permit to t:Qnstruct andrer Ir•eta t the nGrk �•_sf6aa Trie gpprcaGor ie n ae� ^ com; l.a,ce n San <br />.'c,aC6!n CountyDei a cFme t`Title. Ch3pler 9.11'3.3 and the Standerd5 or Ser JceZU:fi Coariry, Envlron.r.oiul 4aa',:n ceparxrent. <br />, r � � W LLL' 61Vj cl:' '� G 1537 A:sa9sOr 9 <br />W9LL Loceuort `t � __ <br />_Groes S;reef <br />PROPERTY Owner .. !� ``ti IrllAddress � �% io `,� CitS per_. Iiag-Q..P*on6a!IF <br />fit r lQo r ,_ city 1 z 54'1 l ,ce 117Let Encase 70_7-5�1� _ 37— <br />C-e7Ccntraao. _ d0reae �? _ toy p —_— _ _ <br />p c.. <br />14460- <br />CcneuttaM'Sub Contracto13 11,1611 rFs: S 1R �i!1>�% Ctt v�jaA�1�k�_,_,?horpp _4SS� <br />G19 Courdlnatee X�•._ _. Y, __^�,_. T�xn9h<fl!_�� Rrer. <br />J' SeCCon_ .._­ <br />WONK TO RE PERFORUGO: <br />KNEW WeLL 1 BORING (CPT. C. C,9ROSE. HYCROPUNZH, HAND•aUC-ER OTHER')` E5TRU'CTIO\ (ct!aose type Debw) <br />C'icti . BORIN3 # U OYER•DOR= <br />'JELL#_ 'jj�At [ M.e II P 4SU^E GROUT / <br />'other: —Gro,t SpaCInCa:ions:_ 5/1 %aA 4z-U-1'e«e pc.'� C:6Lt>•'-t�,,.t' <br />COMMENTS: J7/17io, /19I/.►t3 Z 1-;Wg, 14 ?DeW- L,%e AlItA J -5 ('111V1J1^ Z? <br />TYPE OF WELL INSTALLATION Typip QhSTRUCTjON &PECIFICAT! N� <br />,XMONr'ORING )K,tOLLOYr STEM D.IA. OF 6DREHO-E 8MULTIPLE CASIN3S' 0 NES 0740 SYR ._ : ySING OIA Z _ <br />9 aXTRACTION Q AIR HAMNERICRIVEiN CASING ThICKNESS_._ -'-`?E CIS CASING: LI STEEL <br />f1 VAPOR I] MuD ROTARY DE'TH OF GROUT SEAL _ TRcMIe TYPE TO 5E USSO: XAJGERS Q li 1tit; <br />Q AIR SPARo@ U PUSH POINT GROUT SEAL FLNIFED: Q Yes. KN'(; (NOTE: MAXIMUM FREF-FALL EFTH is 30') <br />0 SOIL. BORING Q HAND AUGER GROUT SoECIFICAT ONS: S%eI"Ua Fe c'; tr�_— ,- ,-�- -- <br />Q OTHER OTHER APPROX. 9oRING uE.PTh tit BOL -ED TF; -.P" C BOX or O GTOvE PIPE <br />CONDUCTOR CASINO PROPOSE0? -,��_ (I 1 YES, 115L 5Peaf W,!on3 hens):_ <br />•COMMENT91 I ,_ . __ <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br />CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN A,DVANt;E FOR ALL REQUIRED INSPECTIONS. <br />hereby cortlfy that I have prepared this application and that the wor i will be done In accordance with San Joaquin <br />County Ordlna k, Rules Regulations, and all applicable Califo N_a State Laws. <br />Sipnadx _ — ThlolCCmponwola'I�ioKMut ,t <br />ern? 48nne--•_ _ -7 <br />_-_ -!+ Date 5�!&2- <br />T <br />-DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS:- <br />WORK PLAN DATED: <br />A9p;cadcr! Accepted By Dote Iseued_ _1irea_., _...__. <br />ceoutlnspedonBy­ Date Finallns;)0CMnby� <br />De ucJon Ins.7syion By Date <br />COMMENTS I CONDITIONS;— <br />ACCCUNTING ONLY: I At DA <br />r <br />PE CODES FEE INFO AMOUNT REMITTED CHECK s Rec'u BY I IATiT__PEB tNYver- <br />C-57! WC,= N/,tzVER— C-57 Letter of Authorization to Siynlpermit_ Encrvacnment doe____ i/Z3/02 <br />To ' d 99S6 686 606 ' ON I I33 Wcl 5g: Z T ZO-20-AUW <br />