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95/18/2008 14 56 2094683433 FIFTH FLOOR PAGE 03 <br /> WELL PERMIT APPUCATION FORI4III UNIT IV <br /> • SAN JOAQUIN COUNTY PUBLIC H <br /> ENVIRONMENTAL HEALTH ❑1VISION (PHS-EfgDES <br /> ' 7 <br /> 304 E_ Weber, Third Floor, Stockton, CA_, 95242 <br /> (20-91468-3449 _ <br /> NOR-REFUNDABLE PERMIT EXPIRES YEAR FRflM DATE ISSUED O!i!V1r{t1}� <br /> 4ppGrauon ry hereby rtnaCe to San.]oapurn County Eon a Demi[to cons'.rtrct ander+enroll tfse worst described. Thrs a aGCats s��((� c�e�n ��• r <br /> San Jaaqurn Ccunry Development TTtia Cyapter�t 1 I5 3 and the St�gdsrds o�bf <br /> f San Joaquin County Pvt>luc Health Services Env ment��I&nvvis on <br /> AiELL Locations 22 11 W Cross Street S J ASsessor's <br /> u iry ip"!$^oZ a percale O`� -�3 i?-1�7 <br />'ROPEJtTY Owner_ 7 rl b,r(e ( Address ( yCc7 <br /> 1 5---`n rty G,�r_ r rv��Y]ra 5 83Ptnor,eiR9�S-D_7 7--�33S <br />:-5T Cartttactor i 1 � r dress � � <br /> qty r �L�c`j.�p` I s321one#�rb- 777-q/Ct7 <br />:artsultarei/Sub Conrac2or 1 Address ���'�' �t CAy �-r Lrdt Fhaned�0'4t`',l�(7-�3�.� <br /> ss,5 Coordwatesi X Y Township <br /> Rance <br /> VORK TO BE PERFORMED <br /> EW{HELL f BORING(CPT GEOPROSE MYDROPUNCH HANG-AUGER OTIAER-y �jEg'f RUCTZ11 choose <br /> Q S 01 L SIM G a � V ER$ type below) <br /> LL a� I.:W . �1 Mw S cv. <br /> Xd ter- {1 ` ESSURE GROUT <br /> OMMJ=MS 0 c1f o� I rr 1 r t ! <br /> rPE O,w L lNST TION TYPE C NSTRUCTION SPE F C.>1 TONS <br /> MMONIYORINGHOLLOW STEM DIA.OF BOREHOLE " MULTIPLE CASINGS?Q YES )I NO WELL CASING DIA 7 f 4,, <br /> �Tt� <br /> EX (-,TION j]AIR HAMMEPJDRIVEN CASING THICXNESS L) TYPE OF `CASING (l STEEL 1-vr- Q OTHER <br /> VA (I mUOROT'AR" OEPTH OF GROUT SEAL + r TFtirMll;TYPE TO BE USED [[AUGERS \VOSE <br /> AIR SPARGE q PUSM -DINT GROUT SEAL PUMPED []Yes o (NbT�- MAYINfUM FREE-FALL D�F'TF-1 IS 30') <br /> 501E BORING I? HAND AUGER APPROX, BORING DEPTH + <br /> f OLTcD TRA1=F1C 6QX or Q STOVE PrP I= <br /> OTHER fI OTHER CONDUCTOR CASING PROPOSE ? (rf YES Its:spcdfirauons here) <br />]NtSVIEhITSy t' u - to VC z7c t' <br /> NATE. OFFSI E BORINGS RFQ1 11RE AC <br /> _SS OR ENCROACHMENT PERMITS <br />:rent'comfy that I ha we prepared this applrr_at4n and that the work will be done M accordance with San Jaaqurn Courrry drd,nancn, Szta Laws aw Rules <br /> I Reg03uons cf the San JoagwrT County Hame owner or Irct"Od 39errt's sgnanue cert f„es the follrnwng 'I cervily that rn the performance cf 1]`re wordy <br /> wrarch th4S permit is issued I zhirfl riot arrrploy persons xsrb/ect 90 W0RK0?S COMPEWW'ION l sws of Calfferrria- Cantr=or's erring or sutr <br /> rt act:ing signature cerafies lollowunq 1 cernyy 2t In rhe perf:armancc of me wvrk for whleh this permit rs=uecL 1 small emplol persons Sublect 17 <br /> JF2KE,4S' MPEIVS.'{T70 Lays of C.ahfamr, <br /> T EAP Ll ANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPE T NS <br /> neoDj�� / _� /1-9 C_7� <br /> 'jjtOate <br />�EE SITE MAP IN UNIT IV WORK PLAN DATED <br /> DEPARTMENT USE ONLY <br /> fiAuan Accepted By Dare Issued % !/L Arse n 7 !Z�� <br /> ut Inspemon By 61 Date Feat Irtspect+on By nate <br /> truanon Inspecvon ey Date <br /> AMENTS J CONOITIONS 4— J"-P_w <br />•C 'iNG ONLY AID# FAC# <br /> CODES FEE INFO AMOUNT RENttTTF-D HECK CASH RECEIVED BY DATE PMMITISERVICE REMUEST NVM6ER IM/OICE <br /> O _5R# 00:)- a`�k <br /> LICENSED COINTI'&-5-C QR�WUST SIG,,r I1CN5E CO2ApE ]5ATIO�lr D£CIA ,T1O7"T <br /> TN- 6/23/49 lsign bkpg/.�t1 <br />