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WELL QRMIT APPLICATION Fdvo�A SITE <br /> MITIGATION <br /> SAM JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHE) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PFRIVI T EXPIRES 1 YEAR FROM DATE~ISSUED <br /> heresy made to San_caauin County for a,permit to c:nstrut=andlar instafE the:nark descritbeC_ Twin apCii;atiorr is made:n t=tNiar.t:8 vr„i San <br /> 3c0n Counry Development Title.Charter S-'115.3 anC the Stareards of San.leaquir,Count;,F;;;lic Haaitri Services,EnNrCnenentat Health L'ivisipn. <br /> =LL Location t!20 � la-��+ - S Qd CrossSireetCe�� ,City Zf„- �ooarceti <br /> F ZCnizTf Owner Q-X 1nQ_rCk LL62,,_Addrass (C)n -C->M1 City Zip��oPhaneM S O�I <br /> S,�P4,;ro-I.C-Irte t Q/1 'f"��{tL � <br /> •57 C,3ntraetor dress_a3koS 11-�1QLQOLVW_ City�z;P� o-r~jr22L�PhanE� O9 x7/ <br /> :nsuEtant:Sub Contractor l��ri/1�i� �/11)�lanNl r+Cc sss Y�-7 E. I bf�. 7e PFCityL / b Phonec�973 0 7 <br /> S cccrdinatBs:X Y Township Range SaC on <br /> OR.1C.L1 Sr: PERFQPM_7' <br /> ! .',V'VEAL;BCRIM1tG <br /> (CPT. E'STR:)CTICN.`chacse type hakrvi <br /> SCIL 3CRlNG M OVER-SORE <br /> {]'HELL PRESSURE GPOU7 <br /> tner: CP^l'T.'^PEC PiCniiOfl. <br /> iNSTALt ATTOYTYr--E CONSTRUCTION SFIECIFICATIONS <br /> 5tS^,iIIT^rnlNiG (]HCLLC1N S i k1 C:A.OF EORS?40LE muL7:PLE CASINGS? [I YES a`IC WE]_L CASlNC-DiA`.: <br /> A;R".:MN1ERlCR"v 17 N, CASING 714.(CKNE55 "(dE Cr CAyi,Vr: (]E i EEL []PVC D O i HER: <br /> AFGR b MUD RCTAARY DEPTH C-GROUT SEAL O AUGERS Q1^OSE <br /> SPARGE D=IJSH PC;ti7 GROUT SEAL =UVPEC: C Yes Q.*tc (NOTE: MAXIMUM. FREE-FALL DEPTH IS 30') <br /> :L°CRf�iG �J HFua%AUv <br /> 30RING 6E•''TH Ij ECL T E0 i,%AF=:C ECX or rl STOVE;:;PE <br /> C-NCL'CTCR A5:NC YES, !ist grec:t7=ti hero): <br /> v�t.�.,��-s: jYl[c9-� �- /rt ua�3 cc.r� c�t� ►n n��e 12r1 �a K �I( 6r <br /> NOTE: OFFSITE BORINGS REQUIRE_ ACCESS OR ENCROACHMENT PlfRMITS ��mui_d <br /> ,erecy certify that I have prepared this aPP11Cad0n and that the work will be done in accordance with San Joaquin <br /> aunty Ordinances, State Laws, and Rules and Regulations of the Sart Joaquin County. <br /> CALL THE u rr IV !NSFECTOR 46 WORKING HRS IN ADVANCE FOR ALL )REQUIRED iNSSPECTIONS Se('V-'tem <br /> Tide!r_Cmo3ny Pi-esl AfQP.'+_ [Al tl�t U Ea U 1 Cc t'1 1Yt P-./i_'Ci I Z <br /> --1:Name fl as a <br /> SITE MAP IN UNIT IV FILE ADDRESS [WORK PLAN DATED <br /> DEPARTMENT J a bNLY <br /> pli;"-tqn accepted By "YYti • Date issued <br /> i� <br /> :,.:Inscection By Gate ^inai lnspectFan By ta' <br /> rjCn insaeCtion Ey Da e <br /> ?-N1'i_4TS 1 CONDMONS: - <br /> 1 jla z <br /> CCCUt�T:NG ONLY: Alp <br /> E CODES FEE JNF6 AMCUtt E RE:dI3TEE] CHECK t ; REG'D 8Y 4 OATS PERMIT/SERVICE REQUEST: 11NV0lCSE ' <br /> 3 0�- R9 ' d° X77 r I _I <br /> C-57_ WC/WAIVER C-57 Letter cf Authorizaticn yo sign permit Enercachrnent dos 7/I7/CC <br /> d. <br />