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<br /> SAN JOAQUIN COUNTY
<br /> N.
<br /> ss ..r (JN 02 4200 TH QEPARTMEN SITE
<br /> c� ENVIRONMENTAL HEAL
<br /> ! 4�''''k:�1
<br /> 600 f=ast Mein Street, Stockton, GA 95202-3( 1R0 ; HEAM lGATION
<br /> Telephone: (209)468.3449 Fait:(209)46$ 3433 INe�:vvw .s RUIC NIT IV
<br /> WELL PERMIT APPLICATION
<br /> NON-f�-EP DA E P PIREYEAR FRPIM Q61F,155619A)
<br /> ApplleaHDn Is hereby made to San Joaquin Covntr for a perma lv consmim endfor install the work described. This application is made in corroiance with San
<br /> Jaatiuin County_Nvelopment Title•chOplPr9-?1?5.3 and the Standards of San Joaquin county Ettvstonmental t'te5Ith Department Asst ssara
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<br /> owner ��_.� Address ...,-�. __ L Y ¢—p -
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<br /> «1.I- ._ Add rtrs S�• W� ._`... city ..�!.kLL&& zip ..�IGtf �_ Phone S-sm
<br /> C-57 Corttrat:tot f,
<br /> -�L 1 1,���c 3571
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<br /> Conr:ullan uq Cntr&MCI ,q RoV Address �a� _..AOfLr.LSL ��!�s ...City —7
<br /> GIS Coordinates:X...... Township Range Section _
<br /> �O PERFORMED;
<br /> 80pjNG(CPT,GEOPROBE.HYOROPUNCH.HAND-4WIll , NEF " C]DESTRUCTION(CIiO09d TWIS
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<br /> Q 503E BARINr;tt— . ... -_— ❑OVER•SORE DIAMETER•,..
<br /> ❑PRZ5SURE GROUT
<br /> C'OYtHER -!kL W. L
<br /> _- -11&4 GROUT SPIaCiFICAT10N5
<br /> COMMENTS. � t� I �• Z � �Z l� SSI-GL�SdriC+tFs
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<br /> L IN T4 L CDUCTIt?N_SPEC1FfC_TA ION$
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<br /> QW OF SOREMCCE .,q{�f�+n ©MULTIPLE CASINGS❑Mtlt'n t�VEt WELL CAVNG DIA,
<br /> MONITORING IC HOLLOW STCM P-��
<br /> T AIR H
<br /> AMMERIORIVEN CASING THICKNESS 3t� ..-._T•YPE OF CASING'Q STEPL 'PVC [3 OTHER
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<br /> [:1fTAAC IDN ❑
<br /> 0 yADpR ❑MUD ROTARY DEPTH DF GROLN se AL . TItL'MtE TYPE TO Wry U941) iAUf3ER9[I I105E
<br /> 0 ArR 8PARGcf02ONF a PUSH POINT tGP ort CP•i)__ GROUT Seat PUMPED:0 yft �1'N0 {NOTE:MAXIMUM FREE-FAI..L DEPTH IS 3D')
<br /> ---_—...L+ROUT ioeC,IPttATIQN3 Cf_ �fU�,,,...
<br /> O Spy,,BOmNC ❑rlatvD AUGER. .. .•.°... _ _-.- '---- .
<br /> ❑pTNt3rt: _._ ❑
<br /> APPROX,BORING UEFTI.1 S 0QdOt.TE•D TRAFFIC BOX OR .❑57OVE PIPE
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<br /> COMMCNTS:-&jh.& d�I•-,.'-I�.. Iz_fL�..c_ .. �� .._..-.__. _ __ -_
<br />! NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS
<br />!
<br /> 48 WORKING HOURS NOTICE R'EQUIREn FOR INSPECTIONS
<br /> .1 hereby Acor,,,,,hal. v a and l pplicatlon and that the work will be done I aevordanco with Sen Joaquin Cotnty Ordinances.Rules and
<br /> Regulgtle ali 1.sws. JL4 —Sipn9dTittercompany 1_LIL� �• �Print NaDate
<br />! DEPARTMENT USE ONLY
<br /> E '
<br /> SITE MAP IN UNIT IV PILE,ADDRESS. •,•,•.�?r2L �-_,(1.�e.t�.�.�a�—��AC�_....... MPY
<br /> WORK PLAN BATED:_.....-. —
<br /> APPIICATIDN ACCEPTED BY �{/(�..nn.. ___ DATE ISSUED /c,w ._AREA
<br /> GROUT INSPECTION BY r�ljpp,�c�-+.,
<br /> FINAL INSPECTION BY U�� .. DATE e S D
<br /> DESTRUCTION INSPECTION BY _-....,..,_. DATE—._,..
<br /> GOrNMEN"ICONDITIONS; ��_- ,--f-.-. •-- -�
<br />! ACCOUNTING ONLY: AI D rr _
<br /> PE CODES l"l:fC INFt7 AMT REMITTED - CHECK fr_ I RECV'D BY DATE PERMITISERVICE 1� }NV010E
<br /> 03 -- �— SR# S 3
<br /> (`•§i WG �. .. -WAIVER .,. _ C57 LEITER OF ALFrHQFiIZATION TO M&N P£ MIT ENCROArHMENT DOC
<br />! END"41 +116107 WELI,FERMIT APP -
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