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6© 11: 16 ^fl946B3433 FIFTH r`o0PA_ <br /> WELL( Y6 <br /> SITE ! <br /> SAN .IOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 453-3443 <br /> Nors-REFUNDABLE orRM'T=KPIPES, YEAR#;ZOM DATE ISSUED <br /> __1i,oticn is hereby Rade:o Sar. 'Caouin County tc.a.7ermu t^,construe:andror:nstall the wcrY daseibeC_ his a;,plf=;iort is made ir.Cam;llz-�we-Sa-. <br /> :acuin Cc::nty Devfetncmenn?Title,'Chamer S--'11 .3 Dna the Stardarbs c,'San Jca�u,r unz.,P� ;blic Health Services.Envirornnentai Hearty, C":vizion, <br /> 'ELL Location 5LD 1 �!L 'Eh S e W L� J Aslsessarlc <br /> e Cross StrAA City 2 oanxt# <br /> ROPER—Y Owne U 1 res6 C',ity Zip phorte� <br /> �T Glrf urS 2i J� l C42—_ RNon,%&-,,oo <br /> W n vlrw y�nim 1 ticesi c. . (nSjSU� <br /> or�,ultarlt:Dub Contractor A�r's�Vr �� Ci L.ic:c a e� �C� <br /> IS CaorCinates:X Y ;awnshlN Range Section <br /> ORK�C SE PEf2FORMED: <br /> ?`!_',V vVEI-L 'BORING CPT.rr=OPDCQE. XY,-CR-_P 1~ E <br /> � � :.H.H:.:Y;�-%,vv .�� OiNER`_` QDESTF?JvTIO.M1!'r-hoose r,�ns bele•. <br /> j�SCtL 3OF ING= `') <br /> ©OVEYc-BJFte <br /> ]they: 0 _�# <br /> GROli i 5F= 0 PRESSURE GRCLr- <br /> ;I�i�..4TEOfV <br /> 0141MEN S: <br /> fpe 2F VVE INSTALLATION YPE CONSTRUCTION SPECIFICATIons <br /> U^uiT^.RiiVG r)HC LLOW S ey7 -MULTi=!?CASINGS-,)(YES [f NC WELL.::.SINOiR: <br /> c)C'RAC'ICn1 C AlR HA-M. VZr0;iV=-N- CASihG-L,'!CKRI:aG 'Y?=OF CASfNC-; [I STEc_ Q PVC t3C 1 HER: <br /> VA"C�R h4 RQT Y ]SPT!-f Or GROUT SEAL. i RENlIF_ Yr-'E TO 6E USt;:r: j]AUGERS 110S= <br /> SP:Fz^E PUSH PCrti T G?DUT SEAL P'U MP_�: es C Nc (NOTE: MAXIMI!. FRSE-FALL DEPTH I i <br /> ES uIL SgRI SG - _ '41 R_- FA 5 3G'. <br /> P1$'1ANC,AL C�F_r URC./U'j'r=4lr vi,I fC�V 7V�Q r �.�j _,�/r• I <br /> GTr=R: Q:rr EF APPR^:x.l30RINIW Je?TH ❑9u:-E:;,AFF1C BCx or a STOVE PIPE /[ 1 <br /> .DhIDU:TGR CA5iNG F'RG?CSED?�� <br /> (if YES,list specirj=tlCns here r <br /> }: <br /> OrMAEK7S: <br /> NOTE' OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> Hereby certify that I have prepared this atsolication and that the work will be done in accordance with San Joaciuin <br /> ounty Ordinances, State Laws, and Rules and Regulations of the San Joaquin County- <br /> " CALL-H UNri IV 4SPECTCR Oar WORKING HRS W A[)V..ANIC 'IDR ALL REQUIRED WSREL,IONS <br /> ;yea x Tiffe/Csmo3nv r 5 <br /> Nit Name s „J. <br /> Date <br /> SIVE MAP IN UNIT Ill FILE ADDRESS [WORK PLAN DATED <br /> DEPARTMENT USE ONLY <br /> :atiCa5on Accepted By Date issued cl G 7 <br /> W1,1spection By date Final InspecSan By Date , <br /> insaecUon By Cate <br /> OMMEYTS!CONOrTIONS: <br /> 4,CGOC1lVTiNG ONLY: AIDS 1 :I <br /> ne CODEB <br /> FEE INFO AMOUNT REMITTED CHECK� � RECD aY � DATE PERMIT/SERVICE REQUEST>F INVOICE <br /> .7 WG`,NAiVER C-57 Letter of Authorizaticn to sign permit Encroachment dac 7/17/CC <br /> tw . <br />