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WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY PUSUG HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DWION (PHS-END) <br /> UNIT Iv <br /> 304 E. Weber, Third Floor, Stockton, CA., 95702 <br /> (209) 468-W9 <br /> t+Io" >^urliDmX"Buff M-MM 1 ffm mm DATE lt4sutn <br /> ppGration is hereby made to San Jcaqui�t Cc%AY fi r a pemtlt b Owstrud taf 4AV awtatl the work omen bed. This appkmMon is made In oomprmfim rQth son <br /> aa�uir�Cra►ntSr Development Tft,Chapter 9.1116.3 W4 the Standards d San Japquin Courfil R�l�c Heel+6e+►+ices,t?mitr�xl�rw�1�Heetlh Diriaion. <br /> d S. M ktv► �533c� P '.a°rj�i o 3 c22� <br /> �..1.r a=tfarrj�z 2 �e-flit moa Cm"sweet c�nl ►a s1P r�l,e a <br /> vmorgTY Dow M r Lt 42 � c ►' ��53-P h m <br /> car corttraotcr C&uAd rpn[LIN C. Ad&ea 2 0 vnt c CI r, aty�°" Z u�r 71 t, ,�► 016 638-I16`� <br /> sue condor DatUn a lrA wtl1 --Amrmeas Ip-] , V I�cin t V1�1 -UaM tahohs�i b- IO a <br /> GIS coordinates:N Range <br /> HYD1W WSrttlon <br /> OEM <br /> fifiVI OE I I CY A <br /> "RW WELL t OMNG(CL'PT SOIL 50"(3H, O-�wGER.QTHF3M a DE57RUC3TIDND � bwmv) <br /> 13 C3 PPX—WLW.OROUT <br /> *Outer Grant 5pmfa3tlarRs. <br /> COMMENT& <br /> TYPROFAMLL m d. mm TYPE EPMER2020 VL2jKIWITtoMs <br /> tWn"G OLL.OW STam DIP.OF 90PJ 10L9! to MULTIPLE CASINGS?a YesW CASINO 0W <br /> T10 <br /> p EXTRACN p AIR NAMMERIDRIVEN CASING rHICKN TYPE or cAs*G; u s-nm. OTHIFR <br /> R VAPOR 11 MUD ROTARY dLPTH OF GROt1T TREKA TYPE TO BE VSED- RUGt3tti J]HOSE <br /> (I AIR SPARGE 1)PUSH POINT GROUT SEAT.PUN PM: p Yea (N0T1c: MJ►IfJMUM FREE-FALL,DEP rH 16 301 <br /> 0 SOIL BORING D t'IAND AUGER GROUT Sr'EOImxnoms; <br /> 0 OTHER: n GTHIE-Ft ApmcDL 6oRtNG oEPTri fl BOLTED TRAF19C SW or &4T6VE P1PE <br /> COND=OR CASING PROPOSED? O (WyM fist tww) <br /> { D G p <br /> +DTE: 61=FSrTE SORtNGS REQUIRE ACCESS OR EN rIACHMENT PEO S. <br /> CALL THE UNIT N INSPLICTOR 45 WORKING HOURS IN ADVANCE FOR ALL REQUIRED IMPEMON& <br /> I hereby certify that I have prepared this i4ppllcaUon and that the wail will be done In accOrdartce with San Joaquin <br /> County Qrdinances, ufcs and Regulations,and all applicablat Californla State LaWa. <br /> 6lgned x,.J�L,u.� �� G>✓-�s Cc��1��'�����,, pr ��G _ Q-P <br /> Print Nor" L4 Vt((4 <br /> DEPWrM—EN,T USE ONLY <br /> 8ME MAPIrl UNrr IV FILF,ADDRESS: 3 `1 <br /> WORK PLAN DATED: ;-z Iy <br /> AppllcaUam AccsptedI @11 <br /> �1 Date 1 3- Arau `� y <br /> Grout knPeedort SY �- '- ?S L �Fir►al Ifupedlort ey '"`� p � �S 0'Z <br /> OBstructtw Ilpedlan 13y l- _ Date <br /> COMMUNTS I CON1171014- <br /> ACCOUNTING ONLYe AJD# <br /> PE GODEa reE wo AMOUNT R>~1Y MMD CHIECK E RECD 13Y DATE PERMIT l URVICE RECUM N INVD$M <br /> 74 716 <br /> G-57WC--..;-WAIUER C-5714+fw of Authorization to sign permit Dieroachmen?doc 9/27/0 <br />