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�eau5 15:13 2094683433 EHD PACE 02 <br /> F . <br /> San Joaquin County. <br /> Environmental Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor, Stookto <br /> IMP (209)465-3449 Fax:(209)458-3433 'Web: MITIGATION <br /> n'C.A.95202 . <br /> m�44W 1' 48 UNIT IV <br /> Well Permit Applicato% 10 , <br /> HON-REFUNDABLE II FIRM•I y�F ^H TA L T Y <br /> AppI40aWn is hereby made to San Joalquin Cnu for a T H F N T <br /> Joaquin Cou +nY Rei+t 10 oonskruct andlot instalf.theanrorkdesp bed. Thls aApllc anon Is made in correpllaetCe witf�San <br /> ►>h'DeYeloprnerd Title.Chapter g-1115.3 and i Standards of San Joaquin-Cou <br /> 0 L - ! ^tY irnr►rr lal Healln VepadrnonL <br /> WFlf-Locarlon 'T eosa Street L�rn[ lLssessurs <br /> city xip- Pat �Q . <br /> 4 <br /> P'ROPERTv <br /> Owner Mck-d 1/12 rvs f <br /> reBs O <br /> Add ' <br /> c-s? �. <br /> Cmfto�or <br /> 1 dressT ,b R,•vet R d <br /> City�e 11`s 23p �h"�f <br /> Consultant 1 sub Crary L! <br /> GIScts c <br /> oordlnares:x Y <br /> �W 30 a LiCax Phone# C(Ife C hi -11-C. <br /> . <br /> Towr>st>rp 13arage Section <br /> ver-QtiK in HE p�0PiNE� <br /> NEW WELL!BORING (CPT,GEOMOSE,HYDROPu1�CH,HANDa,UG�R,oTHt�r <br />+ 0 SOIL BORING# ) 6ESTRUCTION (claansc"Wow) <br /> I []*Other#. Q SURE GROUT <br /> COMMENTS:�J_-- - �'riSi `L GROUT SPECIFICATIONS <br /> PE O1Mr—ELL INSTALt 4 E C S C7i8N SPEC <br /> F IAONITOMNG ., IFrCtwu <br /> Yip- TRACTION Q AI[lAM STEM DIA�IIN THICMBOREHI.fS LTIPLE CASINGS U MUL-nAZVFL WELL CASING DI f f Z r. <br /> !'- Q R HAMMERIDR111EN CAS1r�rG TFffCI� S -TYPE OF CASING; Q STEELpyC Q OTHER: <br /> II VAPOR ty MUD ROTARY DEPTH DF GROUT S ` <br /> ��"R 5PAFRGFJ OZONE Q PUSH POINT(GP or CPT)GROUT S�PUMPED: Y ,� TREMiE lYpf=TO t3E IJSEp; <br /> I]SOIL DdRING D AVGF_RS Q HQSE <br /> p HAND � 0Ido (NO'T'E MAXIMUM FREE-FALL DEPTH IS 301) <br /> GETOUT SPECIFICATIONS <br /> n OTHER <br /> BOTHER: - ^ ►apP�i7x.BORING DEPTH Q BOi_TEU TwtiFFIC BOX Or (1 STOVE PIPE <br /> COt4rN[ENTSR � CUCT R CASiN PROPOSED Of YDS, <br /> q .y list specificatJons in Comment section) <br /> NOTE: OFFSITE BORINGS REQUIRI' ACCESS AGREEMENT OR ENCROACHMENT PERM <br /> 48 WORKING HO RS NOTICE REQUIRED FOR INSPEMONS, �S <br /> I hereby cettlfy that I have Prepared this appll�ation and that <br /> County O nan es, nd R I ns,and all�a �l'taable Cgliforn a the work State Laws.be done In acCOTtilanctr with San Joaquin <br /> PP <br /> Signed x <br /> Print Name <br /> Date a S� <br /> bl�PARTMENT USE ONLY <br /> F SITE MAP IN UNIT IV I✓ILE,ADDRi=SS: <br /> WORK PLAN DATED: S <br /> AWrication AacaMed 13 <br /> Fi <br /> yy <br /> Wgut Iris � Date ISsueD` � <br /> PeOWn II Date A <br /> Desrnxtion Ins seal Inspection By nate <br /> pedian B I tare <br /> CON DENTS/CO NDMONS: <br /> ACCOUNTING ONLY. AID# I <br /> FAC# <br /> FPE CODES FEE INFO AMOt1rQrREMITTED CHECK 1i REC't)BY DATE <br /> 7i sal PERIlfE1T15EiZYrCEREat)EST9 INVOICE <br /> . g9•o� 53F SR# o0yy5 %g <br /> C-57 WC----WAjVER� C-57 Letter of Authorization to sin ertaait <br /> �-W-001 9 P EFncroachmeht doc— <br /> I <br /> Ii <br />