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78l�31��36�7 1} Is 2l7°4hB3433 <br /> FIF;H P_12CT, J"UG u� <br /> - WELL P .-,,01T APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 — — <br /> s <br /> (209) 468-3449 <br /> NON-REFUNDABLE Pr=RMTr EXPIRES 1 YEAR 51ROM QATI:ISSUED <br /> :pli=tic,n is hereby made co Safi Jcacuin County for a permit to ccnstruc'andlar install the Rork CBaCr+beG- raiz wppi'canort is m2de;r.CCCptr&�t9 NnY�S2:z <br /> :acuin Ceunty Development Title.Chapter 9 115-3 and t�neStar arils at San Joaquin, Pudic Hezkth se-- ices;Enrranrn_n"al Hearty Ciriaion, <br /> T-W ASZ2Sscez <br /> 'ELI;Locaticn >vj�? �'t �SCi1tik C__ cross street��,,�} Ci^i ��C� 1�arres#--- --- <br /> CP>=ftTY Owner t rCs Address�� \t~`c C_ �i'_�city C CLC Q, Zip <br /> i <br /> •57 Contractor -W ,t ?ddress V/yv � �e Clrj��� L ZipL � hane~: l -7 <br /> creultant:Sul}Contractor t i `7 ~'s.t `ity �-C �� ?hon2=camp a 6 <br /> IS Cacrdinatas:X ,Y Township Range Sact:an <br /> ORK TO BE PERFORMED]: <br /> �JE'vV rVEt'L,`BORING(C?T. GEOPgCBE. �`.'J�ROPUNC`i.NrNO-nJGER, OTiEFi' ?7 EES-FJCTICN;C`ocse typo-hefo:v', <br /> 4 SC1L 3CR.ING r fl OVER- ORE <br /> 0 WELL R Q PRESSURE GP.OIj7 <br /> lther_ - GR^,I.TSF�C{RsCATION <br /> (FE OF WELL INSTAL TION TYF'e CONSTRUCTION SPECIFICATIONS <br /> ` ONITORING CLLOVI STEN1 O:A.CF 80REHO E VULTIF!E CASINGS? [�YES PJtO NE=LLCAS ENG DSA� <br /> cX". AV";Chl '[j F,iR Hr•i NISR-IORN,EN CASINC3 k.`iICKNESS 'YPE GF CAwfNG: U S.=C- <br /> ,1AFOR p M11UD'ROTARY DEFp'rH OP C-ROU i SEA-9.5 �. T:=cE?�i1�TYPE.CBE 13cE7: ;UGEFS .36- <br /> AA SPARGE [�PUSH PCt'r; �,�r_,UT 5tiRL FUUPeC:Wes Q No �NoTc .?1i AXIM UNI FREE-i=ALL. DEP-f H IS 34' <br /> SOIL SORI G <br /> OTHERZ Q GTr.R APPROK.BORING DERT'q o �S1 �L'Ev TRAFFIC SOX or U STC3VE PIPE <br />'i Cwt1CUCTOP.CA5 vG�ROPCSEq ti3 L {;f Yf S, !ist sgeei6eati,,,5 here). <br /> OMMENTS: <br /> NOTE' OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> hereby certify that I have prepared this"application and that the work will be done in accordance with San Joaquin <br /> aunty Ordinances, State Laws, and Rules and Regulations of the San'Joaquin County. <br /> f•. <br /> " CA T E UNIT ENS ECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS <br /> Tit:/Company <br /> ;nt Name! Da`a <br /> SITE MAP 1N UNIT IV FILE. ADDRESS [WORK PLAN DA D 3a0a } <br /> AEFRRTME'N T EJSE ONLY <br /> )oliCaon FRccspted ey Date Issued- -7`� — Ar`a Q <br /> 'o�;t Inspection 9y <br /> Date r=inaf fnsoecllen By Date_ <br /> 357JCti0ii'If35 Date <br /> OMMZNTS ooNDMONS S ltic vc k rrt(A.)ley-t- I C ��,� :.f o• s 6e N+ &L S f35 <br /> S u5 rl C:J rS L `t` Y�ta4 C-.Q�rn <br /> 3CCOUNTINGONLY: AIDr - 4 <br /> 3E CODES FEE Jl�lFO I AMt}llJyT REy1JTTED CfiECK# �° REG'D BY . DATE ?ERMrr I SERVICE REQUEST I INVOJCE <br /> ,i <br /> 3S-0 I f Fs.-/ _ L 06j <br /> i C-57 WC/WAVER C-57 Letter of Authorization to sign permit Encroachment doc_ 7/17/00 <br /> I <br />