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• -- � �n r�.yrt "AGE 512 <br /> • <br /> WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNITIV <br /> 304 E. Weber, Third Floor, Stockton, CA., 96202 <br /> (209) 469-3449 <br /> Appli atlon Ip ly 11^f r a permit <br /> t F or, aha,l , p FAN S 18N1Fp <br /> nabY made w San Joaquut County for a permit to L�e- and/or InsHY life work deaerl— <br /> Joaquin Courtly Development tlHa,Ohapter g•1115.3 are ma Standards of San Joaqurn County Enulronmental HeoMIl-tato nm0�'daIn C+PmpllancE with San <br /> WELL LocetbrLp2�� COfldtl �V!�. <br /> PRovERrr avne_�1 R1NU�4L%�fYtM 1 c�c��t l5 g b clylC At Lpci,3)C, P a�2�1 12•b'� <br /> cip'i2°yOP on.x419 Q3g SZ 1 <br /> COTSA+n dresc t i InAN,'s}YPr�.�crt•. clry ,nJuSCiZ,p95112 <br /> eonsunentisub cenlra«or�VUlyJ tYIR�yU �resa i�lOQgnGteCLAr� flLlckrL✓ yr toj�� S1U /a3E+ �5D� <br /> GIS Corndinatas:)( y 104 <br /> Seodo,L <br /> �RK TO eta RFOB ; <br /> EW WELL/3 BORING(CPT,GrftOSOIL SO96,WYDROPUNCW,HAND-AUGER,OTHER-) D STRL'CTION(chcaae type below) <br /> oG:l BORIN4# <br /> ELL#_MYd eibd-.c• ROVER-8upE <br /> 'Othar: GrOut t{1etlflCdlione. a PRESSURE GROUT <br /> TYPE OF <br /> L TION TYPE WINbLTROta 10 $ <br /> ONITORING OLLOVr'STEM DIA.OP eOREHOI.E MULTIPLE CASINGS?0 YES�GO WELL CASING DW-_ <br /> 0 EXTRACTION 1J WF HAf�1ElUp31VEN GA81N0 THICKNESS TYPE OF CASING: 0 STEEL"vC 0 OTHER <br /> 0 VAPOR 0 MJD ROTARY DEPTH OF GROUT SEAL _TAME�E TVP£TO aE USED' 0 AUOERt 0 WOSE <br /> tl AIR SPARGE p PUSH POINT 3ROUT sr%AL PUNA [[Yet d No (NOTE: A*IMUM FRE44IIALL DEPTH IS 301) <br /> 0 SOIL SWUNG 13 HAND AUGER GROUT SPEQFIO,TIONS; T�----- YUTA. <br /> 0 OTHER; 0 OTHER APPROX.SCRIN`�DeRTH S�'1 pLTHD TRAPFIC 8pX or 0 STOVE PIPE <br /> CONDUCTOR CA9iN0 PROPOaLi07, (if YEa,lid apeda®6ane hem): <br /> •CQMMENTB: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT N INSPECTOR 4a WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> I hereby oe#Wy that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Orfl antes, Rules 0 ' Regulations,and al(applloabie CaliforniaState Laws. <br /> p <br /> 9'gn°d: -L� -��.-- —TltlWbompany rr(s r IL`ralz _��52�-✓f <br /> Prinl Name_ FJ+•`tiCE /�9c�a�_ _Osie__ !7a �a 7� <br /> DEP USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADD 55: 3a7 a? �.p'yt�t�Q �4 ) 1 <br /> WORK PLAN bATEO: (3 .__ � I rD13 -- — <br /> Applleaann Akwmpwl BYi a4ort Date Waved_.. . 3�3�11­f AroF,�,��Y <br /> Swul lnsper'kn ay tN,i I U Data } R'-/" FinAl Nrapecdon 8y pgre <br /> Oommolon Inspacton By — <br /> COMMlNTS I CONORIONS; —� <br /> ACOOUttT1NG ONLY. AIO# cera _ J <br /> Pri Coosa FBI INFO AMOUNT RE►lfrTED I CHECK# RECO BY DATE PPlnlrti QERVICERtOUEST# INVnics <br /> q 0 b �l l 3 2— —m-dt 3 3_ 0 �7 _ --- <br /> C-V_ Wc,r WATVER_ C-57 Letter of Authorization to sign permit—Encroachment ddc_, 1/25/02 <br /> 7.0 3/d "171J7VV 3DII (Hs 9TEE9SCSOP ZZ :SL h00Z/LZ/70 <br />