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! ` ' -9 - <br /> 1 Fel u k J <br /> WELL PERMIT APPUCATION FORM UNIT IV <br />' SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - -----�- <br /> ENVIRON&&ENTAL HEALTH DIVISION (PHS-EHO) <br /> 3034 E. Weber, Third Floor, Stockton, CA , 96202 <br /> (209) 468-3449 <br /> NODI-R1=Ftjf40AeLr= PPERMIT F_cPi ES s TEAR FROM DAIri 85 UFO <br /> tAupliCation is h+:reny rn2ae to San Joaquin County for a permit to Construe,and/or+zstail the work daSar bed ThYa eppuCetlt7n 's,rack,r oor"'p ia�co will+ <br /> San Joaquin Colirity Develop'nent 1 iva Chapter 9-1115 a and the Stantlards of Sar Joagttlf county Puwue health services Env.�Onmantal Healtn[N.rsion <br /> YfELI.Locatror c 3 WC,ssgsscr'- <br /> G,oss si,eat ► _ci1v G9 in p4_ ,zop oarcei#S05� <br />' PROPERTY Owner (35G%1 TR'. S f 't _Adores_Fa 1&-3 5 Gny Lo d i _—zip 1 11tj <br /> c-57CantraCtor Vd k+1 c�16llih G Addresst20 6ff �_ . .. Pty ►tO�iS�4. 7�pL�cr+ ZQ�I� 1=�n�sit{ 88 S �5. <br /> Coomuitant1 SubCantrac>ar 1".K-f ; blY[i"C)lei egt4ip.attress ebb <br /> CBIS Paan ng,eb X Y Towrts sip FlangeSec tor- <br /> l`lORK TO 8 'ED <br /> 0 NEW WELL i BORING (C>-rT GEOPROSE HYDROPUNCH HAND-AUGER OTHER-) 11 DESTRI JCTIOr. (chcose I�oe bxlowl <br /> �SOII 5,)R[4.G# EIRE her <br /> tit E•IT c"_.—_.........�-- - - _,._.� _...�_ <br /> r t7F Yti'�LL iNSTALi ATION TY� CONSTR jCT60N SP CIFfC naris - <br /> 0 440WTORAG HOLLOW STEM DLA OF 80RSHOLE L_1i_,_ hAULYIPLE CAS,VGSi n YES )(NO +VELI CAS.!G Dc NA <br /> G E.-kAC'iON 0 AIR HA,MM£RlORIVaN CAStrsr THiCKNESS—_N A _ryPE0=CAGING; Q ST17EL Fr PVC [I OTHER __ __ <br /> L-VAPOR p MUO ROTA%4Y DEPTH OF GROUT SEAL_90'teQ� - Rrm&IiE TYPE TC)SE USF_L) C1 AUGt=R$ -*0S'c <br /> Ll AIR SPARGE t3 PUSH POINT GROUT SEAL PUMPED ` Yes Ll No (MOTE MAXIMUM FREE-FALL DEE PTH IS 30'; <br /> SOIL SQRINC.� 1)AANDAUGER APPROX BORING DEPTH g�»-�Qtti k_ <br /> _ [T T30LTEpTgAFFIC eox S"I'01/E Pini_ <br />' } 01 mER - - U OTJ,EP CONDUCTOR CASIt4G PROPOSED? (4 0_{rt YFS hs' spec,ricat dna "e ei --_-- <br /> :- - --- <br /> COIMFMENTS c c W157h Ott 101,F l.� �RYwta �lvtro� Bey <br /> ;qs I F � c - - <br /> -_' _NOTE• OFFSITE SORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS+hefeey certify thel 1 have prepared this application and that the work will be done in aGcpr,anca with Sen Joy cuin Courtly Ora+nances Slate Laws aril R,ie <br /> ana Ru",atlons of the $ems,3oaduin Lou-tfy Homeowner or hconsea agent a signature certifes the foliawtnp -t cerdfy that Jr the,atrfprmance of the wo-k <br /> r4f wh,ch tr+rs P&M11 rs Issued, i shall not am ro <br /> p y persons sublgCt(O WOR#tERS'COMPENSA77t7JY Laws of C8lls'nr7t18" i_'t3­ltracln-s*-rin,=or sub <br />'CQnlla,.'f,n siVnarcjre car%Mes the followtng f certify 7haf/n the p+erikirmarnee of rhe work furwn,c+r r?t+6 p8mrr.s fs$cred sv!,eC',V <br /> rwJr?fERS f Oh�tPw:"JSfiTlvrvLa o{:abloomlas <br /> THE APPL4CAI,I 1llEQST CALL 4$ VVOFtK NG HRS IN AI3VANCE FOR ALL REQUIRED.INSPECTIONS <br /> �T[40�{bLd...i l�.l.._l�_ C..Iteigg <br /> EE ,ITE MAP the UNIT IV WORK FLAN DATED <br />' ` / .��...�.....�.._.�C7PP31fjr145"efa7l,f,at=ONLY <br /> ++pQ,ter,nn h:reptcd Fir_ pate tsaue f�^ ! 9 <br /> i95i+��',i4} 1rrwL+ac..An El <br />'rOft MENTS ' COrdp T2pq4� <br /> CCC}L.'h1T,f t a f31,'�`' AID <br /> PE[:ODES FEE INFO ( AMOUNT REMfTTE.D CHECKC9 REC D VY DATE 1 PERiAIT/SERVICE RSQVEST a I iNvajcE <br /> cr 1 $JQTRL <br /> „1*t �' ill t 12�,f9�aSiCJn rir�'S'Cl/2i j 7 <br />