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WELL PERMIT APPLICATION FORM <br /> � M � E ! SAN JOAQUIN COUNTY MN71�A71�1V <br /> VICE ENVIRONMENTAL HEALTH DEPARTMENT (EHIJ►) UNIT' 11f <br /> 13 DEC 38 PIS 3: he 304 E. Weber, Third Floor, Stockton, CA., 95202 � - <br /> 09 (209) 468-3449 �4 <br /> M0-"EFUNDAR P—"-Mfr FARES I YEAR FROM DATE ISSUE]) <br /> Wic atGn is hereby made to San Jonqum Count rfnr a permit to construct andror inmW tba work descnbed This a--plimtzan is made In co npl+ance unth Sari <br /> oaqurn County De+eelgpment Tom,Chapter 9.1115.3 and the Standards of San Joaquin County Frivir nmantal Health Department <br /> ,yt=t t_Loo<rtlon �o l C O oL �v s czo4c- 4%,Z As <br /> Crass Sntmec tHakura.,_ . P city ka 0 ZE_ 9-5.? Pant# -W <br /> 'FiflPER lY(�wraer C 1Q kAddress Y1 f GtYsAe�.�p9s FhQn�F �Q9 ^3(,7 tf33� <br /> :-57 Conttaaor._ iLT c�I.r�± _ Addmw 15 3 7 S yvR� <br /> :nnsultsnt sub , Address S3 7�s7�,4,�.„I� t�ty�r,LEr � S Prrane `� 1{ 7 f r, <br /> 31S COartlmates X Y 3"ownshtp �tarxge Sectscn- <br /> WmK TO BE PEREgRI4IEC- <br /> WNEW WELL!6oRWG( oPFiOBE. PUiVCH,tiMla-FIU�Rt OI HER6} E)DESTRUCTION(it►oaee type betaw) <br /> CtL BQRJNG#�'`��.�y 7 fd�!'a�. p OVE F-80RE <br /> Q:OLIL '� V ESSURE GRCUT L <br /> Ottrer. Grotrt 3pecrficatstr'� O T J� <br /> '.OMMENTS <br /> .)!Er=OF WE'LL INSTALL.A-110N'F YPE +ONS UCTICN SF'1=CEe`.ATION.S <br /> I MONITORING 13 HOLLOW STEM DIA.OF 90REI-IQLIr 2 rf MULTI CASINGS?t{MUL n-LEVEL?j] WEU CASING 01A:t <br /> I EXIR ACTION U AIR HAMMEFMPJVEi`l CASING TFHCIWESS�_TYPE OF CASING. II STEL rJ PVC jjCTHEJi. NZ&. <br /> I VAPOR 12 MUD RO'T'ARY DEPTH OF GRaL r SEAL 6-3 TREMIE Meir -0 BE USED 11 AUC EIRS OSE <br /> AKSPARGE I OzonexPLISH POINT GROUT SEAL.FUMP5n a Yes ;K No (NA rr=' MAXIMUM FREE-FALL, DEPT1 30') <br /> L BORING p HAND AUGER (3poLmspEaFiCA-noNs. rf 1_.),aNa_ i r1g- <br /> I OTHM 0 OTHER APPROX-HOFJ NG OEPTH :59 U i&Ta)TRAFFIC SOX or a STOVE PIPE <br /> CONDI)CTOR CASING I•RCPaSE07'—(if YES,Test speckadans hsre)�- <br /> COtNN�S: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> _ CALL THE UNIT IV INSPECTOR AS WOMUNG HOURS IN ADVANCE-FOR ALL RlZ-QUIRED INSPECTIONS. - - <br /> hereby certify that I have prepared this application antI that the work will be done in a:cnrdance with S.in JoagUln <br /> :aunty Ordinances, Rules and R Ulabons,and all!applicable Callfbmla Stals Lavers. <br /> +geed x TIt1e�Cnmpy Q` C riz — <br /> "nnt Plartra ` C a <br /> DEPARTMENT USE ONLY <br /> �� _ <br /> ]ITE MAP IN UNIT IV DILE,ADORE5S: � C JS •+- r � ' <br /> FORK PLAM oA7ED: <br /> WICa4on Awe [1 1� <br /> �BX Date � /4 saw_ <br /> trout b ort t3y L7�e `Flnal ImWellon By - --r-- ---fie ^ <br /> las*uckm Inspedim,BY DLa* <br /> xya�ITs r ccworrloNs _ <br /> ACCOUrYTNGCNLY: Am# <br /> alh-InEs Ft E INIF=o AMOUNT REMrrrED CHIECKO RMID 0Y CAve � PERMIT r:'0;nRCE REQU aT# I VWE <br /> WG -UI%ANER C 57 Letter of Authorizelian to s�gro perrm� Encr,.achn writ doc, v 8/29102 <br /> i <br />