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ORIGINAL <br /> WELL, PERMIT APPLICATION F0RfV1 SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SE VIC.IES UNIT 1/i1f11 ITV <br /> I {]Ri <br /> ENVIRONMENTAL HEALTH DIVISION (PHS4EHD) <br /> 304 E_ Weber, Third Floor, Stockton, CA.., $5242 D� <br /> (209) 468-34-49GReGG <br /> NON-Rt-FUNDABLE PER►VIrr EXPISRES•t YEAF.FROM GATE SUED <br /> A:;plica l:,n is hereby made to sar,,ioacv;n Gsunty for a per-nil,to ccns4ue.and!or ir,stali,!�e work described, This application is made in compria-c9-with San <br /> ,,oaqux,County De:.etopment'ride,Chapter 5-i 7 tS.S and the Standar-s of$an Joaqul,11 County Public Health Sen-.ices,EnvironrnanW FaAaitl't Division. <br /> D Assessar' <br /> WICLL Lucaticn /[_`Z 03 6y� �6—_Cross Street ` __City A'`-Zip <br /> FROt'EF:''1'Ownei�s06 61r Address O�L`^`� "`� Ci', lL� ✓��u�ZpZ Phoneme 7q1�` iTY l4 <br /> C-5?coatractar �rciftfOA AddrpSs �� l e—ICS- CIty/./��r lK IG�yZLic#�hone <br /> Consuim-el/Sib C:. mctor tT-"T��`�� Address /SOX/�¢zC Cltyo'�tic# 07 �PhcneR �'To�' 5 <br /> i <br /> t?iS Coo,d.nate:s:X� Y_,Tomship P.ange: 5ectian <br /> I <br /> I+Vi1RY.T7 CE fiER>°Orc�1AEt?' i <br /> ^JEV WELL j fiGRltr'G�GECPROSE.HY ROPU'ICH,HAND-AUGER,OTHER*) i p DESTRUCTION (moose type belov,.) <br /> U SOIL SORING ' i Q dV"R-BORE <br /> # - - 1;F'F?ESSURE GROUT <br /> "Other: Graut Spodfications: 1 <br /> COMMENTS- <br /> IN <br /> OMMENT S- <br /> rFc OF WE.�t I) STALLAT gN Tt'PE CRhSTR�CTiON SPECIF;CATIOWS <br /> a MON i 7-3RiNG u NGLLOW s-I-Em DIA.OF BOREHOLE M?JWTIPL E CAS!rv�S7[}YES KNO WELL CASING DV,: <br /> EK,PArCTION QAIR H.AMMER;rRIVEN CASING THICKNESS_ TYPE OF CPAING! Q STE-SL []PVC Q OTHER: <br /> MUD RO'A>;Y DEF17H OF GROUT S21EAL _TREMr�T�?E TO BE USED: a AUGERS POSE <br /> Aln SPARGE PL!SH PWIiJT GROUT Sa L PUMPEC,-X('es G No (NC.,TE:1 MAXIMUPA FREE-FALL DEPTH IS 301 <br /> Ii SaL F3OR!NG �� 0`LAND Al!uSR C•RO-,.1'T SPG i=!C?TIONS:- /l/r <br /> X HER _`'^7�ER - APFRCX.BORINv DEF'TH,� .--iI �LT't0 TRAFFIC BOX r�r p STOVE PIPE <br /> 4 ti ., <br /> CON`JJCTCR CASING PROPOSED? /VC (ii YES,list IpecifcatwOns here;: <br /> ' COMA:ENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCR ACHMENT PERMITS. <br /> --EALL THE UNLT I><' INSPECTOR 48 WORKING HOURS IN ADVA-N- CE FOR ALL REQUIRED INSPECTIONS. <br /> 1 hereby ce;jify that I have preparad, this applieatior: and that the V40.*w)1f be dare in accordance With San Joaquin <br /> County I rdi an a Rules a Regulations,and all appticabie Califorrtiia State Laws. <br /> Signedx _ Tifle,Compary <br /> Print Name <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT f f'FILE,ADDRESS: �� � �`� to _ <br /> WORK PLA14 DATED. (v-210-0 Z <br /> A.?Plr<<tion A r°pled E r - —Dote Issued _ -0,2— <br /> Grout <br /> 0ZGrout lnspecfaan E;r _ Date— -- Fna:Inspection By ; Zug () Data!f"to -o <br /> Destructon inso9cticr By Date <br /> COMMENTS r COMMONS: <br /> ACCOUNTING ONLY: !!Y4 ! I' <br /> i; PI_CODES FEE INFO j AMOUNT REMITT`.:D ONES K# � KE�'C�8Y I DATA PI�17 t SERVICE REQUEST# -VOICE <br /> � tz-v18 <br /> 032-0 D _ — <br /> _, <br /> C-57 WC -WA1VER_ C-5.7 +ter dr sign pPrrnit %'Encroachment doc 9/Z1/DC.' <br /> I <br />