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WELL PERMIT APPLICATION FORM <br /> -NVMD E Ing KALIA SAN JOAQUIN COUNTY Mi GgMON <br /> - M� <br /> EN'11MRONNMENTAL HEALTH DEPARTMENT (END) UT [1f <br /> 03 DEC 38 pH 148304 E. Weber, Third 0Fl or, Stockton, <br /> CA., 95202 ) � <br /> 6w,ISSUED f 1 <br /> NOA1-i25F[J�IL]1u31� E#ZlYlff E7CPlR1ES 1 VE.AT�FROM QA i <br /> joatfon is hen by nmde to San.Iaaqurn Countyfor a peamt to carsstwot andlor mOad the work descrrbed Thrs apprrcatlors a made i a=pb ince vAth San <br /> um CormtY Development Tlile,Chapter 9-1115-3 and the Standards of Sin Jwuin County Fnvironnwntat memm DgmrhneniL <br /> .�5 <br /> � ERI Y Ommer _61_1hForT H Qaf� e. addrem 31 1 STH _� � c a n�ZIP P 0694 <br /> Gtrniaaaar Address 7 S► 4w <br /> suttant 1 Sub Crri3 .C, F- Address_ 7 s R d 4.ity S ra.Kfo,+L,co:_t—Phunel 2 S! Y 6 7-Y 00 <br /> Coordrnate,S_X �.�. Y .,...� .Town" Range secwn— <br /> W TO BE PERFpW11 D- <br /> EW WELL I BORING( EOPRORE,HYIJF({JPUNCH,HANC� UGEX��7 ��}l=8TRi1CYlON(choc�type bCiaw} <br /> SIL i30RlNG# !/ U1 OVER oto <br /> wa=L1 ; q Pim 1F�GROUT <br /> _Grout SpeCllc�Isprts. d1 f rr�a .. <br /> 4MENTS - <br /> 5 OF Y&L6 IMS iM1.A-n0N TYPr CONSIMUMN SF94r-W 'n01@S /� <br /> 7NITORING 11 HOLLOW STEAM VIA.OF SQRE-IOL4 Z . mU.TIPLE CASINGS?U MULT}L VIEL7 Q WELL CAS NG DIA;n <br /> TRACTION 11AIR 1•iAMMMORAM4 CASING THICKNESS.-N/4- TYPE OF CASING n S1 F-E:L n PVC <br /> ;POR Q MUD ROTARY DEPTH OF GROUT SEAL S d F T, TREMIE"TYPE TO BE USED 11AUGER 5 Se <br /> �ARISE/Ozone PUSM POINT GROUT•SFJ- PIJi PC0 fly n No (NOTE• MAXIMU IIA F EE-FALL DE PTH l 30') <br /> WBORING q NAND AUGER GROUT'SPECIFICATIONS Q J - <br /> t -1132. f!OTHER APPROXI BORING 087rH 5,o 1 r a$tLT mAFFIC BOX or a ST QVE PIPE <br /> CONDUCTCR CASING PROPOSED* && (if YES,FRt sr ec fcatlorts hereJr _ - <br /> '7 <br /> MOTE; OFFSITE BOPJNGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> CALL THE UNIT IV INSPECTOR 118 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTPDNIS <br /> areby certify that! have prepared this application and that the Work vAll be done In accordance With Sass Joaquin <br /> unty Ordinances, Rules and Regulations,and all applicable Calidomi Laws. <br /> sod x --I TitlelCorr�rY 1 ta�. <br /> t Name Cl o 'd, C vt/I Dale �'J <br /> DEPARTMENT USE ONLY <br /> -E MAP IN UNff IV FILE,ADDRESS. � 7� �• � �F-- <br /> 3RK PLAN GATED' dc-?— <br /> Scadon A=pted 91- Issued <br /> ut Irmpedlon By 17ese fTrrel InspeWon BY �� <br /> &uetlon k BY Daft <br /> 7 a 1 Ct�ti'itON1S <br /> CCOUNITING CHLY AID1v <br /> DES �INFO AMOUNT PiEmn l� CRECK 0 REC'R 8Y DIP TE p1:RJsi�r1 SE=RVIGs>E REL1l1E3'T WVQIC>~ <br /> 57 INC -WAR C-57 Letter of Aut'homdPonto sign per At Emi oarhment doc <br /> r <br />