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' 02/1712905 13 47 2094683433 FIFTH FLOOR PAGE 02 <br /> og -G San , oaquin CountyMirORIGIFY1 <br /> " Environmental Health Department ITE <br /> IC' r^ter <br /> �E. K 304 East Weber Avenue.3rd Floor, Stockton, CA 95202 �GATION <br /> www(209)468-3449 Fax (209)468-3433 Web www sjgov or�� NIT IV <br /> Well Permit Application <br /> NON4tMKOASLE FEIRMff EXPIRES 1 Y6AA FROM DATE 183UEM <br /> Application is hersby made to San joaquo County for is pemtto constrvot and/or install the vxmt desori ATs Omptiance with Sari <br /> Joaquin County DevelopMent 7Mle ChWar 9-1115.3 and the Standards of San Joaquin County Ermronmen� �ssan <br />' W>`iL 1.otadon `]� 111 �� {Sa M as Street r c n wary 5 d-cc 1 4b,�Zlp`��2- �aroel# �a <br /> owns 0 Address 131!6_ .��f�a1 Qty,SrW� F,',- r' p}cb�e F+hcnadf:5(-Z 4 Z!2 S 11 <br />' Csr CantMctw s io 16 K.,hz i I R_1w—city Am f'Rn <br /> CorwAftr,tISub om6e, J1110 4C_ CMS-4 dress3lsl rtir 5" '`ca�tyf�sfKr�rassLah s�L� �herse 7� 96 -X 33 <br /> GIS Coordinates X Y ,Township Rang- (e -- <br /> BEd <br /> NEW WELL I BORING (CPT,GEQPROSE HYOROPUNCH HANID-AiJCOEER,OTHER) q DESTRUCTION (choice type wow) <br />' IISOIL BORING# p OVER-BORE qwJ-TER_ <br /> •LWELL# 16Aa PF�S^sLIF2E GROUT <br /> d'Omsr �� GROUTSPECIFICA-nON5 <br />' COMMENTS. <br /> TYPE OF YM INWEMiAnom CONMWUCTM SPEC1lrA't'pONS �7 <br /> 0 MDNrraMNG �HOL LCW STEM DIA.OF RORAHOL.E„gff u MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA.y <br /> a ffxm T N o AIR HAMMEROMEN CASING T HrANESS,Irdg..�(Q TYPE OF CAsmr. p BTM& 'jj�C 0 QTH iEP_ <br /> )VAPOR a Mea ROTARY DEPTH OF GROUT SEAL. -� TREWIE TYPIS TO 9E USED- ;VUGERS 0 HOS@ <br /> Q AIR SPARGEI OZONE q PUSH POINT(GP or CnGROUT SEAL PUMPHD• I]Ya; IZ No (NDTE. MAXIMUM FREE.*ALL DEPTH IS 3W) <br /> 10011.90RVt3 0 HAND AUGER UT SPECIFICATIONS �"'^+ <br />' STH» _ h OTHER �RQX BODING 0 TM 7 _ - M ED TRAFFlC eO( or g STOVE PIPE <br /> 0 f CONDUCTOR CASING PR0P0SED j , —(If YES,Ida sPecillmOOM Irl=mywr m sscton) <br /> COMMENTS +_ a4iz&r* <br />' NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WOMNd HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby owtify that I hvm prepared this applleadon and that the work will be done In accordance with San Joaquin <br /> County Ordinances, Ruip and Kegel n ,and all applicable Califtrnia State Lair <br /> Slpned <br /> Print Name le"a-C-1 ef o rr Data �-"��-R„g= - <br /> DEPAR7MENT USE ONLYy <br /> SITE MAP IN 111111T IV FILE,ADDRESS: W 4T '�- <br /> WORK PLAN DATED' AD 1( V <br /> AppNoadon Acospted lay Data Issued Aroe <br /> Grout Inspection Sy Date Rin2l Inepacwrn By e <br /> OaS caan Inspection By Date <br /> COMMENTS J CONDlTIDNS <br />' ACCOUNTING CN1_Y AID# FAC# <br /> P[COpfi9 FIRE INFO AMOUNT 1lLIIIp7 TNp CHECK 0 RECD EY GATE PER=!SERVICE REQUEST 1x INVOICE <br /> 1 MW lk r 101 9j SRl<1` <br /> 1 C-3T W4Z -WAVER___„ C-57 Iztter of Authorization to sign permit E=ncroachment dec 0 <br /> 6rM3142401 <br />' srzv" <br /> 1 <br />