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Received Mar-03—e9 12:59pm %so, from CCITT G3 i AQUA SCT _�E page 2 <br /> -3-03-5-5120 1 _02PIA FROM `� P-2 <br /> r <br /> `= <br /> 4 WELL PERMIT APPLICATION FORM UNIT IV <br /> pr1 1: 56 <br /> ° SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> tr, <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 488-3449 <br /> NON-REFUN A E P Pr/,1T EXPERES Z YEAR FROM DATE i$SUED <br /> Aapiication!s ri>re y made to Son 3oaqui;County tot a Perini;to construct andlor insta!I the w rk described. This appticatlon is hack in Compliance with <br /> San Joaquin Counly Development Title,Chapter 4-7'75.3 2nd the St2nd3rds of San Joaquin County Public Health 5arvl,, Envi: ss ent r Health Division. <br /> � q f' w J,/f a Assessor'r, <br /> (,7,6,'. Lt ILO Cross Str6et irnV AW City� ., Zip 7s? <br /> WELL Location 5 f <br /> zl�r�a+�1 S I+ Address 3d �t1� _City�Zip9S�Phoneg YIZ <br /> PROPERTY Owner s11e' <br /> ddre5s $!d Ndc,9�. Gi;yl'f�✓lfia+r Zip9 JY.53l.iG4' Phone# �p•Lsf.3dQ <br /> S n r: r/Ia ��. anea�_�d,re. `d LJ- dCG_r erre �lJ <br /> onsultan ,..ub.Go.�'"'s9 ��i <br /> GIS Coordinates:X Y Tvvmsrti Nm <br /> 1h'DRK TO SE PEF,FOReAED <br /> r r , HYDROPUNCH, HANG-AUGER, OTHER-) U DESY•�UC7lON',choose typ, <br /> ��V l'1_LL1 O :l3�G(CPT, F G_OPRO.ae <br /> �SOII EORING" G '1 0.tid c../7`T z-- Q OVER-50R;: <br /> D PRESSURE G.RCU7 <br /> J <br /> CQf,1fv1ENT5: <br /> TY?=OF WELL N$TAL LATIC"TYPE CONSTRUCTION SPECIFICATIONS it <br /> " .•hONITOntNC 7�ii0'. OW STEM <br /> OIA OF EOREHOLE_"' MULTI?LE CASINGS?0 YES **NO %HELL CASING DIA: _ <br /> p EXT RAC rioN G <br /> AIR HAi M1ZF!0FUVcly CnSiitiG THICKt:ESS S'-� d TYPE OE CASING: u STEEL PVC !J OTHZR: <br /> 0 VAPOR o rJ;VO ROTARY n;; TH OF GROUT SEAL :3-' TREMIE TYPE TO BE USED; (AUGERS DHGSE <br /> pAli.SPARGE 0 PUSH POrNT GROUT SEAL PUI"PED: p Yes Ivo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> p SOIL 9pftING 0 HAND AUGER APPROX,BORING DEPTH /5 _jr:E0LTE0 TRAFFIC BOY, or 0 STOVE PIPE <br /> aTkcR.� T[]OTHER CONDUCTOR CASING PROPOSED?�n---(if YES,t,-t speciticalions <br /> COMMENTS: Apes v ]�di, a �P h o + Jr1e� <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby certify that I have prepared this.ppiir ition and that the work will be done in accordence with San Joaquin County Ordinances,State Laws,and F.'Ui3s <br /> and Ragviations of the San Joaquin County. Homeowner nr licensed agent's signature certifies the follovting: "f certify that in the performance of the work <br /> for which this permit is issued,f shuff not emptay persons subject to WORKERS'COhSPENSAT10N laws of California," Contractor's hiring or su5- <br /> contractina sighatvre certifies the following: '1 certifj that io the perform6m2 of the nrork for whic,7 Mls permit is issued, 1&NiW employ persons subJcet to <br /> vYOrzXEEAS•COIOPENSATfON Laws of C2lifomia," <br /> CALL THt`UNiT'IV INSPECTOR 48 WORKING HRS IN ADVANCE-FOP,ALL REQUIRED INSPECTIONS. . <br /> Sinned x��l.LG.f L(,,1t �/ — 'FitialCompeny 1cGt- �''Z/4�"1+t- C.l <br /> Print tQarneJj <br /> s1� T' dalaR�cy <br /> 1<CW1C�t.R-C/[ D1=PARTIv1ENF USE ONLY Q <br /> Aop!icolion Acce^,t�d PY- _ _Date Issued r 0 <br /> Grout Inspection By Date Fina[Inspection By Date^� <br /> Destruction Inspcketion By Det< <br /> COMMENTS f C0,7PITIONS: <br /> I <br /> ACCOUNTING ONI.Y' Air)# <br /> Pt:CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 3101 M- z4 t�fz 14*-1 o oa r <br />