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I SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> 600 East Main Street, Stockton,CA 95202-3029 IMTIGATION <br /> low TeNpNone:(209)468-3454 Fax:(209)468-3433 Web:www.sigov.orQ/ehd UNIT IV <br /> WELL PERMIT APPLICATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin Candy for a permit to construct andlor instaN Ure work described. This appl'Icotion is mode in Compunce wNh San <br /> Joaquin Candy Dsveiopment Tlk chapter 9-1115.3 and the Sbumlimds of San County 6Nironmenloi I Will Depwinowd Assessoft <br /> vLocation357-7. w <br /> rwla�Street Q 33 City��sL►5_zip� <br /> P'°''ef t'yNorvt�l a 4 Num 4v- Address a h f ve City Ke dLA zip` qjd Phare# 15 6- I 1 <br /> c a Cmrbaclo. ►41ft y city i �pq�fPa4 t is#28 32�o Piwne�'3 <br /> consufterwseti cna I3t n kgUm-SAKAadm/000 Ota k land- LiasPhone 559 35 710 2 <br /> GIS Coordinew:X Y ,Towrsldp Range Section <br /> WORK TO BE Pte: <br /> 0 NEW vtlEl.1JUOIMN6(CPT,GEOPROBE.HYDROPUNCH,HANDAUGER.OtHEIr) Ap mrRI1mm(CHOOSE TYPE eabm <br /> 0 WELL## O PRESSURE GROUT A•75/r <br /> 0*OTHER GROUT SPECIFICATIONS <br /> 0 EXPLOSIVES DETONATING CARD <br /> CONMiENTS: M W'� ►,}��-1 f � 3 <br /> TM OF �Q5t- o Tm D nuc o <br /> MONITORING )I�STEM DIA.OF BOREHOLE Lj5- O MULTIPLE CMOM 0 MULTI-LEVE. WB.L CASH DW Z <br /> 0 EXTRACTION 0 AIR HAMMEPJDRIVEN CASMIG THK"I ESS TYPE OF CASING:0 STEEL PtVC 0 OTHM <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL_1.D,_.�Tmaw TYPE TO BE usEDNAumm 0 FOSE <br /> 0 AIR SPARGEOZONE 0 PUSH POW(GP OR CPT) GROUT SEAL PUMPEI 0 Y" 0 No(NOTE:NAXMIJr MM-FALL DEPTH IS M <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIF CATIONS I B rl(R si d ce pil e n f <br /> 0 OTHER: 0 OTHM: AM=.WRING DEPTH YQ `, <br /> -7 5' O BOLTM TRAFFIC BOX OR O STOVE RIPE <br /> CONDUCTM CASWG PROPOM (IFVM.FA spsdlfa- in- , -soc*m) <br /> COMMENTS: <br /> NOTE: OFFSITE BORNIGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKNO HOURS N0110E REOMED FOR 918MUM <br /> Mrs <br /> I Mwby oerhNy and that the work willbe done I aecordonoa w Mh sen Jow it Com*Onlirawoesk Rules and <br /> �yA'. - Jc— <br /> SVwdl fJ/IW&Agr <br /> r`'�,� <br /> Print Name W I��I a/W1 S�O W 1 Data 6120 <br /> SITE MAP IN UNIT N FILE,AODRES�' <br /> WOW PIAN DATED <br /> APPLICATION ACCEPTED BY DATE IS3U® D AREA _ <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE COM FEE R" AMT Rmwrm CHECK# RECV'D BY DATE PER111111IMERVICE# rtVIWE <br /> a aZ o' 610' p l (0 /� /0 slMt�v <br /> C-7 VMC WAIVER C57 LETTER OF AIJTHORQATION TO SIGN DOC <br /> EM 29-01 1028M VWRL PERMIT APP <br />