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^. 31 _332 13 : 46 <br /> WELL PERMIT APPLICATION FORM F IL g 8t — <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPAillIMENT ( EHD) UNIT IV — <br /> E� n 304 E , Weber, Third Floor, Stocktim,, CA. , 95202 <br /> SSS - (209) 488 -344S' <br /> IQN•REFUNDABLE REKNIT EXPIRES f YEARIFROIJ. Q,,a.TF ISSUED <br /> App:icamr is ha% CY made fo San I )acuin Ccu;Ty for a permit to cona;ruc( dr;d'or IRi!a Iha nprk deslib!cI San <br /> oaain County Derelcpme-i Title. Chapler S•i t 5.3 and the 61a.nderd5 er Ser koclit, Seamy._:-ndron.maital Faal:n CeparTnent. <br /> __ — 13 [ T - 4537�=2rc*I aar9 <br /> WELL Loo l Creed S:raei �[r,LCI �Cl. -arcdo- - _-- - <br /> PROPERTYOwner '�_ > `"• odreasJ� W r�f>{Cn> �' 1 �,, 1P1- L7- Z1;+ (� <br /> C-67 Cur.irac!o:_ Ju``E- (� 11 ddr9as (QD �lt J.st, _Cly ��}Lj ZipgS��Lcr 1771GM Pnc.+.a3 p7�U�7 $p^/j • y <br /> GcnsulfanI ., Sub Contractor 8i Ar.A., 11,dT. , jI,1"y,,_f+ydrt,&; f' S Y•rYMJ �Nt •t0 a-'L1drY__•_—?norr,p r •[�(�(._4550 <br /> CIa Caurdl.^,afar- X_,, . _ Y_-77„__-++ _ _ , Tdrn9%ID—_ —__�_ __ Rnra• J' <br /> WeI TO BC PERFOR4cn: ( I\ 4Z•t..�.` y.'r_l(5 <br /> KEW NV ELL I BORING ( CPT , Car09RO8 E, HYO ROPUNOH, HAN O-AU SER OTHER') F; ;; ! F5TRI IO\ (cifnose type oe'orr) <br /> /� �" . . . BORING # _ q�--�� U OYEF�00RE <br /> /'cLL # rNw.-Ij �-�w-r� 5 �� J P 9SU ^.EGROUT / <br /> •CUIrK: _ _ _G rout SPOCIRca:io:is:. f9 (--.�-'}aute <br /> CONIMFNTS; �71,v 12163 A s Pla-�e. (ne_k% GVLUJ -•��!/J//�/�Z? <br /> TYPE OR WELL NaTALLATION TYPE - ATIOJ(� 1 <br /> SiCNI"'ORING OLLOSTEN ` DIA OF BOREH0..E MU, TIPLE CASIN36' U NES j�TIO wE : ._ CASING DIA. . <br /> / W 0 iXTRACTION p AIR HANINER'CRIVFN CA91NG THICIQ•fES3 ^TYPE CP CASING: LISTEEL )(MVC 0 OTHER: _ <br /> [J VAPOR [] MSO ROTARY DE'TH OF ROUTS EA TRENII- TYPE TO BE USSO: AUGERS O IioSt <br /> UAIR SPARGE 0PUSHPOINT GROUT BEALPLWED: aYac, <Nc (NOTE: MAXIMUM FREI3 •FALL EPTH1530•) <br /> n SOIL BORING QHAND AUGER GROUT Se ECIFICAT ONS;_�> �2 �� V W«_._ ��N (�P .1•�as .__ <br /> OTHER_ APPROX. BORING "uEPTh�tO!T- '�BOL'EO TR-.F C BOX or (J GTOvr PIPE <br /> CONDUCTOR CASINO PROPO$t0?j, k _ [ .f YES, 8Laprplr:.eflo1ahcra;:_ <br /> ' COMMENTS; I <br /> NOTE : OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADV4Nt) E FOR ALL REQUIRED INSPECTIONS. <br /> I hereby certlty that I have pre ared this application and that the wort ; will be done In accordance with $ an Joaquin <br /> County Ordlns Er <br /> s Regulations, and all applicable Callto filR State Lawn. <br /> Sianadx-- ._-- �TI!ICICcc�pcn>(• CR �Cct b)*PI'"f4M&L.Rr.'l �1ye rlc <br /> Prn: hems ��-- -- - <br /> � <br /> DEPARTMENT USE OSI LY <br /> SITE MAP IN UNIT IV FILE , ADDRE5S : ' `7 067- z eze? <br /> WORK PLAN DATED: <br /> AvoleaionAccepted Sy <br /> Gout Inspedon By. , <br /> Dcm don Inso• ctlon By Date <br /> COMMENTS I CONOITION111 : _ <br /> ACCOUNTING ONLY; AIDn - <br /> car " <br /> PECODES FEE INFO AMOUNT REMITTED CHECK • ReC'U BY I-1ATit PERMIT : 36RVI6C REQUEST@ f INVOICE <br /> C•57! WC=WAIVER_ C-57 Letter of Authorization to signlpermit_ Encroachment doe_ - 1/25102 <br /> , \ ' — I ' <br /> pa <br /> TO MCI <br /> 9SS6 686 606 • SNI I33 Wd SC - ZT ZO - 20 - ekUw <br />