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0al23f:aa2 1_:46 <<9- `3-133 <br />r • :. <br />FIFT:-i; F1 0:R <br />r <br />P L =E .' <br />WELL PERMIT APPLICATION FORM SITE � + <br />a SAN JOAQUIN COLIN!'* MITIGATION <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD UNIT IV <br />�c }n 304 E. Weber, Third Floor, Siock6n; CA., 95202 R f <br />S� (209) 488-344S,� <br />NQP(-REFWNDABIE PERMIT EKPIRSB 1 YEM'FRjM QATF ISSUED <br />s[ F:I:.al ar � Is he',1Cj made *.o San !)ac.ir Ccuimy for a pemll to anatruct ard'cr Insta I the nark &.4s rit!d TNe applicatio-'.s rva_w r comps a -ice � , n San <br />Ajacn County De\alcpme-tTiUa. Charter 9.11' 0.3 snd the Sta.ndard5 of Ser .lce2i a Ccum,ry, cnvlronmentsl �dat:n Cep arsrent. <br />�jj II ` 0Q ntfD A;Sa5SCr5 <br />T <br />vrELL LoceuorLrt�fc�1'l _--Groes StroetC I't : <br />PROPERTY Oviner k �%+�,ItliAddre�a� W a Cit <br />C-67 Ccrtrac:o-. 'ucENA Adoress IQ� f _� CI ' • <br />tz <br />S�% L,ce �77��1 P^.o^.ao 7U7- 4�Y�'ta <br />C19 Coordlnatst X,.._ _. Y_,•,• ____„��-, Torrn9h�—_�,— __ Rare• J"' Section_ .,__�. <br />WQFtK TO RG FERFORUGM! % r- V-�� j <br />4EvU WELL I GORiNG ( CPT. CfJ9R0SE, HYCROPUNCH, HANJ•AUC-ER OTHER') ;,•_ xCES T R+JC�TIO c nose we Dc,orr) <br />t~Ex.... <br />GO RING _ VER 30R= <br />T/ELL S_ �/ P aSu'^E GRQUT / <br />'Other:— — .-._GroitSpeclflca:o r:. 5!c.i�o_ --- <br />CONINIFNTS: <br />LYPE Of WELL 114TALLATIOd TYPIi <br />1M:,Nr'OR1NG "HOLLOW STEM. <br />0 iXTFACTION 0 AJR HA!AMER'CRI JeN <br />[I VAPOR p MUD ROTARY <br />U AIR ZPARaff U PUSH POINT <br />D SOIL BORING (j HAND AUGER <br />Q 0 -HER _ _Q OTHER <br />,COMMENTS: <br />AT!0bn ; <br />DIA OF 13ORF-HO-E_ MULT!PLE CASINr35- U', ES NO W F .- CgSING DIA _ <br />CASING T)hICKNESS_._ _ '-"PE CP CASING: U STEEL 'D1.1C a 0. HER:_ r <br />DE°TH OF CRGUT SEAL _ TREt,nlc TYRE TO 5E USED: �JGERS Q li 1�t <br />GROUT SEAI_PUM=ED: 01'ac.(NU (NOTE: MAXIMUM FREF-FALL9EPTH is 30') -- <br />GROUTS"JECIFICATONS: �i I �c' jo.tjr P)E�Atc 'r- C <br />APPROX. BORING:;FPTh `BOL'ED TR••.F" C EOX or I1 STOvC P)PE <br />CCNDUC,'rJR CA31N0 ':f YES. IIeL apearae;rons h_re):— <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS._ <br />CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVAN!'E FOR ALL REQUIRED INSPECTIONS. <br />I hereby cortlfy that I have pre ared thlS application and that the wort; will be done In accordance with San Joaquin <br />County Ordlna Z, Rules Regulations, and all applicable Califo <br />ny1aState Laws. <br />Tltlo/Ccmpbn)� ,Etel,rsl%IIttJ11 rL (hvrS //r <br />lC <br />7 <br />—Date <br />—5�7—`--7-'_— <br />DEPARTMENT UAE ISN <br />SITE MAP IN UNIT 1V FILE, ADDRESS: <br />WORK PLAN DATED' _ <br />Ap kac orAccaptedBy <br />Grout Inspedon By_ Date ^_ FIn3! U15?t3Ctlt)n Dy-,^Dato­ . <br />Dmruelon mrneylon By Date <br />COMMENTS I CONDITIONS: <br />ACCOUNTING ONLY: Al DO <br />PE CODES FEE INFO AMOUNT REMITTEDCHECK i Rec'U BY 1011'1? P aT 0 INVOICE <br />C-57_ WC,- V/AIVER_ C-57 Letter of Awthorizofivn to sign,permit_ Encroachment doe_ r 1/23/02 <br />T0 -d 9996 686 606 <br />'DNI I Aa Wj 99 = Z T Z0-80—d1ow <br />