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SITE <br />, MMGATION <br />UNIT IV <br />4pplicabon Aeueceri <br />3n:rut Inspedion By <br />JesSection Inspeclier 5 Deis f <br />:oMsigsiTs I G CMGs ITIONS, <br />66,W <br />Lit)P <br />11/20/20IMI 16:48 19166385611 <br />!--2 , ^7.0: ; • EK4C.:::, — • <br />: 92 .? i RTGINAL <br />‘io WELL PERMIT APPLICATION FORM <br />/SAN JOAQUIN COUNTY PUBUC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />/ 304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 488-3449 <br />R214-4tEPUNDAntrEltainEXPIRO Laws FROM DATE MOM <br />Is hereby trees 12 Son Jon:AM Gambino.. non* le construel wridio- Instal Pre work deso-10•0. This s,opleeden Is made In cersplisnos $lis Jpequin OiounlY Drolopment Tit*, Chapter II-1118A tone Ow Man:1mM of San 41:egoln County Pubic Herein Sinlow ermitirmatsi1SS5I ONIslon. <br />S Location !_fLP 4-IL Q e.Ativse iC6)fes SeNsel LOU 6fAiti4z01.40hitetY" Alp %-.33 ()Perna 1 7 —130 - -- <br />Assessoes <br />2cir, PROPERTY Owner C P ILL( eSidekess 1S-c13 S NIA-1-1-114 City_ tPfSA e-CIetapc632)Dyhans0 ?Z- /(i 75 <br />*A a AgaZa11151) (Awe —IRA <br />Consulbnt I Sub Cornnictor IT Ctec e. Menses <br />!bk. sitcrQ <br /> Lk", car - 3c3.0 <br />Sill Cocrinetst X . Y Township Rang. Seeger <br />iletk i.i. / EicnINOt crr, GEOPROCE, HYDROPUNCH, liAND-AUGIER. WHIM') <br />PEI/POMMEL <br />0 SOIL SORNO 0 <br />XAIEU_•• NI W -s LO 1 <br />C.87 c: C4( <br />'Often <br />COMMENTS: <br />fl DESTRUCTION(dgloss type Oakrw) <br />DovemactmE <br />a PRESSURE SIPSDUT <br />Omit Spsellesgens; <br />TYPE OF MU, KOTALLonortYYPS <br />VAONITORrN XcIOLLOW <br />3 EXTRACTION a MR'HAMMEFUORIVEN <br />a VAPOR a MUD ROTARY <br />MR WAAGE B PUSH POSIT <br />a SOIL BORING fl HAM AUGER <br />OThlet: f) OTHER <br />'COMM54T11; <br />II <br />DIA. OF BORE MULTIPLE CASINGS? a YES VI40 WELL CASING D( 2. <br />C.ASINO m UC.kt4Q TYPE OF CASINO 0 STEEL Ifi•VC <br />corm or (OUT SEAL, 2- TREMIE TYPI TO MI 1.11111D; MIO* 11 HOSE <br />GROUT SSA. PUMPOD: a Yes )04o (NOTE: MAXIMUM FREE-FALL DEPTH IS 301 <br />011:11.1T SPECIFICATIONS: <br />APPRQX. sonING Dorm cAkf VaocraibTRAFF)c BOX or g WWI PIPE <br />CONDUCTOR CASINO PROPOSED? NI) II TVS list gfecN1010iorlo horiX. <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br />CALL THE UNIT IV INSPECTOR 41 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />prepared this application and that the woo* will be Oone In accordance with San Joequin <br />sand Regulations, end oil applicable California State Laws. <br />C2p s PrjJ 00 <br />/. <br />Dots <br /> TitithiCam y <br />PEPARTMENT USE ONLY <br />1 c) ese--1 Gn INC(ger <br />NORK PLAN DATED: <br />hereby rtt1ypt I h <br />County Ord <br />Ei good <br />Pri Native kl et e-cl <br />SITE MAP IN UNIT IV RILE, ADDRESS: I tg <br />Acc,outrritio ONLY: ADO Flefiii <br />, <br />PE CODES F EE INFO AMOUNT REmrrrao CHECK it LVTTIIIIIR 0 ,SNES-R1WIIST INVOICS <br />1 9 I --MIA) MINVIII'° '.-- 111W rM111111112Lin, : 00240V- <br />_ <br />C-57 WC -WAIVER__ C-57 Letter of Authorization to .sign permit - -nclochVnsflt