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T1'/21/2001 13 10 2094683433 FLDOR P4GE 02 <br /> 1110412001 15.08 2094693433 FIFTH-L <br /> WELL PERMIT APPLICATION FORM SITE <br /> © MITIGATION <br /> ct SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 1= 304 E Weber,Third Floor, Stockton, CA^, 95202 <br /> (209) 458-3449 <br /> NON 1tEFU140G6L1-PERMIT EXPIRES 7 YEAR FROM DATE IS$UEP <br /> Applicatan Is hamdymsade t�San Joaquin Qounty rD a penntt to con3tr=and/or wn-W t rhe c ork descr*�ed nis sppGc�aan.�mace ir,oornp6anu w+tY San <br /> Jeaq�County,bewlopmenl Ttic Chapter 9-7 its 3 and rw Stanaaras of San Joawn County pub l.c Neam Service s Eriwm imenla1 Meait?1 Dlvssion <br /> � Assessa�s <br /> VdFLt tncsnon 7 / l�+r Cross SurpA rr if W City .�s•kc�. r. `5337 pavceaa <br /> UPLKT-y0„�er1rn C <br /> bij,n nddmss �X7 Z yOjCmi <br /> PR <br /> � � ��n�� ay� z�o <br /> � �33� Prone: 1 C <br /> C67 Gartractor 5 979 tae t.^3?2y .t /,elegy cry ah zipW7V2 t L;3 Y9WPnonex_��k 0'e-72)fi j <br /> Como!WK I �;r�,c ►•-arf c% G 06 0 92 S ZD <br /> Sub ronuvaor-- �_<jM Address Ghjl�.,y.J1r L�rrs`f� Ptsotx <br /> GIS Cmxd�neL-v-X Y TownsNp R.3nge <br /> VMKX o g RM IED- <br /> 17 NEW WF-LL I SORiNG(CPT GEOPRODE HYD NCrt 11AN TKER') OESTRk=0N(&oose*Pe beow) <br /> `�7 " t]OVER-SORE <br /> W 9 fys — d 14/— PRE_SSURE GROUT <br /> `Other GroutSD4otte <br /> HYPE Of WELL lmEr ym nm i;QNSTRUC"SPEUnCATIOUS <br /> Q SING Wxl-ow STEM DLL Or SOREHOLEL�_MLILTIPL.E CASWG67 O YES 1 NO VVGLL CA5L4G DIA _ <br /> E7CTFtnr`TION Cl AIR HAkAsdEROMVEN CA-caNGT?flCKNFSS�_TYPE OF CASING B STEEL *VC 0 OTHr:R <br /> VAPOR p MUD ROTARY DEPTH OF GROUT S i' TREMAE TYPE TO HE USEDGERS 0 HOSE <br /> +►Iii SPARGE 0 PUSH POINT CROUTSE&I-PUMPED IY re, Ho (MDTE:MAXMUM FREE ALL DEPTH IS 3G`) <br /> n sotL BORING 0 KAW AUGER GROUT SPECIFrcarian�_-7A <br /> 'T t_ C1�ioo~J7_ <br /> to OTHER t1 t7THER APPROX SORtNG DCPT-H 7�Q_ )(BOLTED TRAFFIC sox or a STOVE PIP$ <br /> CQNDUCTti�t CASING O {K YES,Met epeaF�arts►>arek_ <br /> -GOMAt�tEMrTs <br /> NOTE OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERM TS_ <br /> CALLTHE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIflHS <br /> I hereby certify that I have prepaned this appll on and that the weric will be done in accordance with San Joaquin <br /> County Ord les wind Requ s,and all applicable California State Law '�} <br /> Slorred>c !/SCI trdia�•�e+- "2)a4 Cut <br /> Pr'ntN e. v4•o 14bale //-139 f <br /> DEPARTMENT USE ONLY <br /> SfTE MAP IN UNIT IV FILE,ADARESS- A,O a <br /> WORK PLAN DATED d <br /> AM*-.Awa s9r o IszMdl ,I/ I Area <br /> Grave'"CeOR Date 1,W.0 . By Data <br /> De irmcdo,irmpedim>x <br /> �I£IiT81 Ca![DI�IOI'IB <br /> ACCX)U r0JG NL1f AMS <br /> !E t:Otlt:S PEE SFO R/10l�MlTREfRTTED c>}lEGlt REM BY DATE MIMI <br /> RIECROEST a: INV O1GE <br /> 3 F <br /> C-57_ _ WC -WAZVEI2 C-57 tetter of Atftarezateon to sign permit Encroachment doc_ 9/27700 <br /> • <br />