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WELL PERMIT APPLICATION FORMA SITE <br /> SAN JOAQUIN COUNTY >=l BUG HEALTH SERVICES rM1TIGA1ION <br /> ENVIRONMENTAL HEALTHDiV1SION (PHS-EHD) I - 1 1__IIw�IIIr;_ <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3"9 FEB 1 1 2002 <br /> ppGcatio n b inaroby rade to San Jaaquil Co"ter-&permit tC w n&ud altn 1w axtall ti»worts*na bed. TMrs appiicallon is rhbde)n oo�ian <br /> j Wran Courtly Deft4apment 1-ft,Chapte!r 9••111 b.9 and me standerdwof san j"qui n C�Public F aaw Servk=,�mir»Nnseltai� P ya�}� <br /> TELL Location 508 S- tFGca R Cross steet8ow�an d _City F2r1s� Carj} 31P x5231 P$ }�� 2 <br /> RopcnTi+ Monl�rU'f�},lp. l cam_ ,4ddrees �l5aa S. <br /> an �d Frrr,r.�Cg p�Pt,Q,.t,S2o�l�gB2-1y�3 <br /> ccr,traam+rya t 17r+(�i Ad&es00rec Cc rc I carr + _�+a42k- 61 o <br /> rsuacontrador � al Ico7?,�-;✓ karrr�„�c�vs�i��� �Li� - 0 <br /> ,iR <br /> JiS Coorcl�a:X •Y - - -•Towrssttlp Range-- - -S�ar�--•--.-- - - <br /> CW WELL)BORING(CPT, oPRosE.H,rfl HK <br /> , o-AL►C#R.vTHEW) a oda+c��►b <br /> (3 80 $ofc!�,-V. 0 OVER-WAr <br /> �"0�W-1�FCSN- -1 BCW-Z wr5�. a PREsw.dsuour <br /> Other. _ - - <br /> ;OMMENTS <br /> o 121& AMUN TYPE CotisTRUCT10f1$fPLtIIcICATI� / <br /> ra<CLL.Ow STELA Im of BOPA40%x- it. MULMPLF-CASNW?a YES Bfjo W ELLc.A <br /> . SiNG 00- <br /> (i <br /> I EXRAGrK)N 0 AIR KA.U114ERMRNElJ CASING TIHIC1 Na= rypE or CAma; n s-ri ci. PGCOT <br /> I VAPOR Is MUD ROTARY DEPTH mom o TREws TYPE TO BE t mo: � HRR:om allose <br /> 1 AIR SPARGE p PUSH POIN"r GR=SEAL PUMPED: p Yee (NOTE: MAXIMUM FREE-FALL DEP rH Is 301 <br /> 1801L BORING Fi HAND AUGER GROUTSPMIRCATiD+rls:-C,0Y1 OnI11+7 W� 4 So% ber1+pt-I1{Z <br /> I OTHER tl CTI- P APFR0X 60R$NG OEPTN 13 BOLTED TRAFFIC SW Tw 4L60VF PIPE <br /> CONDUCTOR CASING PROPOSED? Nb It YES,fist s -CAMUC rte b")• <br /> colwlu>:rrrs- tl pn-iy _ <br /> (C eek U 4LC Mtu+ . <br /> NOTE: OFFSfTE BORINGS REQUIRE ACCESS OR 5NCROACHMENT PERMITS. <br /> cALL THE UNIT N INSPECTOR Ord WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIaN& <br /> hereby certity that I have prepwvd this application and that the work will be done In accordance with San Joaquin <br /> ;ounty, Ordinance Rules and Regutations,and all app{ica California State Law . <br /> 'tuned X -I Gl � r i nd I <br /> >rtm JDV1I (L � OE WMA USE ONLY y <br /> srrE MAP IN UNIT FV FILE,ADDRESS: <br /> wows PLAN DATED:_,_ <br /> qkppticatwn Acre, By <br /> "1 �v oats issued— <br /> / <br /> st Z <br /> Grout irsspac8cn By v2- irvl InspoCtlort By QdIF �7 b <br /> :)Bstruc5e)n Inspedw Ry Cge -_ <br /> caMMaNTS 1 CONUT10N5= <br /> AC=r-C TING ONLY: AJD# <br /> PE caUDEs rEE NFD AMOUNT REMITTED CHECK It RECD BY DATE PER [T]SERVICE REL'1UEST N PNVDtCE <br /> S FM2 <br /> C-57WCC-WAIVER C-57 Letter of Authorization to sign permit ErurooChment dcc,_ 9/27/0 <br />