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1'I WFLL PERMIT APPLaCATION FORM S <br /> s.z L E <br /> SAN AQUIN COUNTY PUBLIC HEALT�SERV[C�SI ON <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) U IV(.QO4 <br /> f' 304; E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 1lJj� <br /> I, NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Applica:�On i5 hereby ne-Ce t0 Sal rC2Q:;i- <br /> .1 C-.un j for a perm': ..,tc consl" an_.:•.-5:2fi:he u�f't de5(7i�t�. T`�rS aapiica:on - <br /> is made zornp!iance w:,,h San <br /> Jo2qu;n Coan:y Develop.nenl T iae,Chapter E >>15.3 and:re Stara zS c'San J-a -,n Co irty PUaiic!ea':h Serv'ces,=rdr-re :a:-Iealln Civision. <br /> +1 Assessors � <br /> WELL Lavation 1904 Cant Club FSM. C css Street 'Dian �Ci y Zip Parxl�- _ <br /> 1I `` -- /�� acckt _ <br /> PROPERTY Owner�s*,-7 C.O .add ess Ale-.C,ty Y?, .�f Fron£c r/lo <br /> C-57 Cor.lr=or V8W a-Mirg Im - Address P-0- BDX 51 C I). ]1 o Vista.Zip-±5 71 Lic= hxi 720911 707 ��4�815 <br /> e= <br /> Consultant l Sub Contractor Gdress 1 % B. ._.City � Li-," 5177 Pno-e# 530 156&5300 . <br /> { 4 <br /> GIS Coordinate s:a —,Y To.tirsh o 1N Range 6E $ECJon <br /> 4 , <br /> WORK TO BEiP.ERFORMED: <br /> NEY1 111ELL11 BORING(CPT.-GEOPROE_`HYC4C-1 'BCH,1-AND-�LliG=R.0 r HER-) 0 D=S RUCTPON(moose type below) <br /> X SOIL BCR:NG � p OVER-BORE <br /> }h'ELL za PRESSURE GROUT <br /> *Other' <br /> I �G•o.:Spec:1catrors: _ ! <br /> COMMENTS: � <br /> TYPE OF WELL+ - EiNSTALLA,T)ON'TYPE CONSTRUCTION SPECIFICATIONS <br /> • ,. +A - 0Rc�QLE �� r:ULTIPL= CAS;NGS?a YES O WE:L CASNIG✓!A of <br /> iN STEM, C= .C"B.. <br /> �!ulONITOR3NG , :�,F•IOL:O �� , <br /> EXTRACTION 0- I)AIR HAA1lfcR/GRIY_N C:S:^1G 7}'!G C^ESS C TYr'C OF CASING: p STEEL '=V: 0 OTHER: <br /> (�VAPOR I o MUD ROTARY DEPTH OF GR s =_;��! TREMIE TYP€TO BE USED: ]AUGERS gHCSE <br /> II <br /> AIR•r3FARGE 0 PUSH POINT GROUT S=Air P:JMPED; -SYes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> ;&SCIL BORING II HAL140 AUGER GRCUT SPECT-CAT,C1,S- N�atOeTEnt with 5%bEntaaite <br /> I)OTH. - n OTHER , APPROX.BOR!.%G DEF-=r $0300=1) RA F-r IC ECX or [)STCV=_P,PE <br /> C:NDUCTOR CAS:N,-:P=cOPOSED?� (:f YES,fists r.Lcabons herd): <br /> -COMMENTS: <br /> NOTE: OFFSITE BbRINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> GALE.THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> I hereby certify-that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordin ces. RuIP nnf+ p„^ '-i0=7s, and all applicable California State Laws. <br /> Signed x f I s e'ComprnyWestern Ce --a'gin7 <br /> Print Name L. Ccr)ver5e Date ~.'LOO <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: L d �• <br /> WORK PLAN DATED: =T zo,aa Vd : !Orly-00 <br /> j, <br /> App:icaUon Accepted By Hate Issued _ ea <br /> Groin Inspection By <br /> Date Final Inspection By to <br /> Destruction Inspection By D <br /> COMMENTS I CONOrrIONS: —D <br /> ACCOUNTING ONLY: AID" - <br /> PE CODES i FEE INFO AMOUNT REMITTED CHECKS RECD BY DATE PERMIT/SERVICE_ REQUEST# INVOICE . <br /> I / �CC7 1-23-0 In 2. <br /> r <br /> C-57 WC -WAIVER C-57 Letter or Authcnzcticn to sign pernFt Ertcrocchment dcc_ _ 4/27/OG <br /> EErEF:gt'E3Z E. CC4C,Z/.TiC4I <br />