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ORIGINAL
<br />WELL PERMIT APPLICATION FORM SITE
<br />MITIGATION
<br />SAN JOAQUIN COUNTY PUSLIC HEALTH Sf= �MC.ES UNIT IV
<br />O �N"
<br />ENVIRONMENTAL HEALTH DIVISION (PHS4EHD)
<br />�j 304 E. Weber, Third Flexr, SitOcktGn, CA., 9520.2 ON
<br />(209) 463-3449
<br />Nara -REFUNDABLE PERMITEXPtPLES I YE.AF. FROM BATS SSUEU
<br />is hereby :Wade to S rn Countf for a peri it to ppn9;-Ucr ander install ,I :e wGrl described, 'This application is merle in complianr, with Sar,
<br />UcZgU,n Gl-)Unty 0Vveioprnent Title, Ghop,er �- t 7 ti:.3 and the Standar.: ; 0$n-oaquln Ccun y Pubiic Health Ser -ices, Environrr,ental health Division.
<br />/[� C c Assesz-o.'s
<br />WELL duC::Wcn ! o -T ovM ry e,/�yid�a%vtvrosr Street _��—City , I Q om/ Zip
<br />FR 0p>`R7"1' Owner SCo C dd, _ss " « — �.� F C_0 phone
<br />:,? c�,tactor (SSC _,f�%pr/Y`c` r",ddresS 3r3z Onfti CiC�clty limo Z,rf.?—Z.ic, �5/0 Prone9ff`0h'-/<69
<br />wonaal:a at / S Jt G.� :tr^�LtOr f�"'/ �G`� ��/'�-� Address ` '� �y�-� It,�✓�=tLlc# Phcne 7�4�-�eZSv�
<br />CiS C:oo i- atk s: ; ;,�--•_--- Y T pwnship Range' 5ectian
<br />i
<br />WORK TO CE PERFORMED: I
<br />Evv v"ELI-I RORtNG ; ^P T; GEC?ROSE, HYDROPUNC i, HAND -AUGER, 01HER"j U DE$TRJCTiON (cnaaso type below)
<br />$Ott- SORING # ❑ OV=R-BORE O
<br />Vt1'E: L # I; PRiSSURE GROUT
<br />'C)ti'Ger: _ Gro;�i Specifcaticrs: j
<br />-ON1MISN7S
<br />YFE'3F WELL WSTALLA*20N TfPE CONSTRLtCT, ION SPECIFieATI lJS
<br />I
<br />01,C)NIT, 3RING P(rIOLLOW STEM DiA. OF BIDREHOLF- f - M1);,TJF E 'AS,:tVPS 0 YE$ P(NO 4NELL CASING: DIA: a
<br />u E. RAQ-TIOh i1 AIR HAW,1-ER'L",RIVEN CASING THICKNESS f—�, CIO 7`!PE OF CASING! © STEEL APVC 0 OTHER.
<br />-
<br />r VLID ROTA' ;Y DEGTH OF GROUT i2EALI 70 (.7 - TREMtE T- PE TO BE U$EO' a AUGERS (HOSE
<br />XAih SPARGE r! PUSH PO::NT Gf?OI-T raA.L PiJ :•1PE^;- X`es U Pio (NICTE:N1AXI� FREE -FALL DEPTH IS 30,:
<br />S :SOIL G��RtN�G D ARS u0Z'R GROkiT SFS ^ _=!CA.TI:)V$: /7 +
<br />i; t *rHEP,:'_ —4 17i;E - APF.-PZCX. BORING
<br />CONDU'-.'TCIR CASING PROPOSED?
<br />"COMMEN
<br />Q(IrOLTc'0 TRAFFIC BOX or Q STOVE
<br />Y -Y l it,YES, I'.stspecifcations here;:
<br />SeCe,
<br />----- — NOTE: OFFSi T E BORk€ GS. REt, U RE ACCESS OR ENCROACHMENT PERMITS.
<br />vCALL THE UNIT IV :`4! iPECT0R 4$ WORKING MOORS IN ADVANCE FOR ALL REQUIRED INSPECTIONS.
<br />i hereby rce: tify that; e p.epar_-d thin, application and that the work will be. col a in accordance with San Joaquin.
<br />County Ordinal s Rule an ulations, and all applicable ualiforma State Laws.
<br />Signed x /
<br />` d
<br />DEPARTMENT USE ONLY
<br />SITE MAP IN UN7 Rf F'ILE, ADDRESS: ! aZ Ai;4_lxth
<br />WORK PLAN DATED: �O - -O'2 -- r--
<br />n.pp'kztlon ,�� pted E ✓ - ---Date ssustl EMD �� ��
<br />Grot:t!nsNeef:,r. f5r- ----- Date— —Final inspection Sy Data
<br />cstruU:0n. insogctinr. By Vale _
<br />CL'MMEiNT$ I CONtlMONS:
<br />�AC:O'J1vTINr ONLY: A1D#
<br />I; s'E CODES FEE INFOAncUh; �EMIlECHECK � I REVD BY I OATS ERMIT ! SER EST # ; INVOICE —
<br />�1 1 _ 2-q 5z �,�112--3 -o --I--
<br />C--i-y��AT4cR_ C-57 Letter ar Ajthor,-'--anon to si5n permit enc 912 /Ol.
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