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WELL. PERMIT APPLICATION FORM WY <br /> ME�i�i ��Ai<��� 1VII{ IG�►T1ON � <br /> t � S i i SAN .iQAQt3iN COUNTY UNIT INF <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 43 on 38 PM 3-. 48304 E. Weber, Third Floor, Stockton, CA., 95202 � a <br /> (209) 485-3449 01 ! l; , <br /> NON-IMF[INDABLE PEPMfr S 1 YEAR FROM GATS FSSUED <br /> iCahon is herehymade to San Jaagwn COU*for a perrrnt to cvnstrvC#andinr kali the rvojt[desrnUAd Th�.s appgrat n o made+ !�ince with San 1 <br /> um County DeveFopr m2nt Title.Chapter 9.1115-3 and the Standards of Sm Jaaqum CMMty ErMM111TWte1 Hw,'l#t G m - <br /> L Loc lien t;'J7 �N nThIc & i�•1Y 5 a"1`I <br /> ggoysSLt ANTan, - - Z 4 <br /> ipFIYOw++err1- �r N a G Address —Ly dty_� ��oa�,9s � �/Ph4� ��y__ 3 S9 <br /> Addra�s 93 r4 S W 9Z G-y ETbC y��'I a� <br /> suttaAt!Sub Crit: <br /> Fp� City foClf�gnLidt �?_LPhc�ef# 3`( y b 7--f Dir <br /> Coardmallm X YW10 FIE PERFIJ DIS STRUCTION(cam tse We below) <br /> m-W WELL f HOR]NGy( EOPRCBC,FF`lD PUNCH,HANG AUGER Mme') � ORE <br /> CIL BORING ip !RE GROUT O("j rvla - <br /> �. Groert 5peaflsatmns; .�.�-------� <br /> �tMENTS <br /> I <br /> OF VIl7 ,1 tlusr 77a1d iY>a CONSTRuc770W sP£CIPFCA7IONS <br /> D.N]TORING 11 HOLLOW STEM C)IA OF BOREHOLE Z`' �y,iUULTI�CASINGS?a MULT}fit 2 2 wr-U.CAS NG DFA. /'1 <br /> 1 IA <br /> ;7RACTFON 13 AIR AMER/MVEN CASING THICKNESS r -.TYPE OF CASiNS 13 Si twEEL O PVC f]crrH=4 N <br /> kPOR i3 MUD ROTARY DEPTH OF GROUT StJ1L S G�rt. <br /> TREMIF-TYPE Z O 13E USEn []ALIC-R 3 St= I <br /> ARGe! ne�lPUSH POINT G�t'U-r SEX.,PUA�P� 11y, a No (Nc)TE• MI)QMIU M P EF--BALL D€PTH Ism') <br /> �OAING d HAND AUGER Gin SP£OIFlCA'n0N , – <br /> rHE:;- pT}{ APPROX BORING DEPTH �� r r a sa-TM TRAFFIC SOX or Il$7 DVE PIPE <br /> CONDUCTOR CASINGPROPa.SF�?� (af YF_Si,fssi sir-ciCdllQns here)__—03— <br /> NOTE; <br /> NOTE: OFFSrTE BOR3NGS REQUIRE ACCESS OR ENCROACHIf[ENT PERMITS <br /> CALL THE UNIT N IN5RECTOR+)S WORKING HOURS IN ADVANCE FOR ALL RE UIREt7 IRfSPECTIi DNS� <br /> weby certify that I have prepared this application and that the work will be dame in acocirdan4O wrth San Joaquin <br /> Linty Ordinances, Rules and Regulattons,and all applicable Califot' i a Laws. <br /> 1ed s Tit[eiCy 1 <br /> #IVarre <br /> DEPARTMENT USE ONLY <br /> OP <br /> -E WMP IN UNIT IV FILE,ADDRESS: <br /> 1�dj All. � - <br /> )RK PLAN DATED: el <br /> �F �� <br /> �lEca#�n Aua pt�ect 13g Das>z Fvad Inspeedor►By --- Date <br /> ut FnspeWlan Jay — <br /> drocftn kmimctlon BY Date - <br /> F1 MENTS I CCMTFX s <br /> CCOIJFriTING 9F�tl.Y <br /> ES F�1HFC A1110�JF1FT R£�Ilff rED ['NECK# RCG'rS 8Y DATE p�fl SF'_�VICB REQUEST� WOM <br /> Ftp==hment doc - $!29/02 <br /> 57,____,- WC -WAIVER C-57 Letter of Authorization to sign permit f '�� �� ✓. <br />