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10-05-1999 12 50PM FROM P 1 <br /> OCT-05-1999 Oe 47 CAMBRIA 510 420 91.70 P 02/02 <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> . SAH JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EMD) <br /> 304 E.Weber,Third Floor, Stockton, CA., 95202 <br /> (209)4G"449 <br /> NOty-REFU90A WE PERMIT EXPIRES 1 YEAR FROM TE ISSUED <br /> Appba team ss hehsby made to Sari Joaqun CounlY Ice*Permit to oonatruct anslor eaI3II on work daw+bed Tthis aQpl csYlon�s"We m oompuance wmtn <br /> �g�nlat HNtTn G+v7� <br /> San joaqum county De velopemrtt Tule Chaotw 9-1 tt s 3 and u%e stsnwrds of San Jopqutn County Pwbl c Hoalsls Sen+�ce3 Enw nma <br /> t+UIELI toeathon �� t' Crocs Strtei Ghgr Z� �0 AParaedr r -Jb � <br /> f! <br /> PROPEMff t]rner Q I PE's' Ghr Z'p Pnane+r r�5-?51 '4 <br /> s <br /> C-67 contrado= <br /> SA QA �adroasI+� Sf. . _-camR►clt r� t 43- -73;7-`1S►S <br /> C �1a11 Adoness t1�I �Sb'� _Cay �a vhorvti► - ��3 y0 <br /> Consultsnz I Sub Contractor, lftA <br /> GIS Ceerdlnites X Y 7ewnsmp $�` Range a� SetLlon <br /> Wog K TO QE PERFORMED <br /> d NEW WELL Opti PT EWROBE.HYDROPUNCH } 0-AUGUR G HER7 D DgSTRlIGTtt11°`r�ER4ve ty�r.below) <br /> p soil-eORING s 13 <br /> fl 1N6Lt.i D PRESSURE GKOtlT <br /> COMMENTS.E Mf. 1NSTALLATHM TYPE CONS SPBCI 02-1 <br /> D MONITORING Q lKou OW STEM DW OF sOREHOtE n-W. IALILnPLE CAStNG57 D YSS D ND YvELL t,ASWG OiA <br /> Q p(TRACTION Q AIR yAMWER1DRIVEm CASING P-UGCNE$S TYPE OF CASlKG' D STEEL Q PVC D OTHIER <br /> d VAPOR p MVO ROTARY f3EP'TW OF GROUT 9F 4L` TPZMIE TYPE TO BE USED D AUGERS WOSE <br /> D MR SPARGE Q PUSH POINT GROUT SFJ PUMPED D Ytx 0 Nd (NOTE: MAXIMUM FREE-FALL DEPTH 15 30') <br /> $pIL SORING D NAND AUGER APPROX_BORING OEPTH Q SOLTEO TRAFFIC BOX or D STOVE PIPE <br /> . D OTfiER �GT118 _ CONDUCTOR CASING pROAOSED� (8 YFS Jaz speafirat>ans Here)_ <br /> GOurME11Ts � a <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> ihereby ceroly that I have vmvargo th4s ijip-6=04 and that tht wfwA wd1 lit done In ar,,cords-Ce wdh San Jmyln Cau++ty Ofam neas'sow Laws.aro Rules <br /> and Reguouons hof tae San Joequm CeunrY ftom0ownet at tce*sW agent's stgnsWft eertrfies the fOROwnW'7 eerby llr.f m the performance of the work <br /> for wAirb fats Peo I of i3 sssued,l shah!Hol eapW pefFws&AA0 to WRAWj"'COKPEmSAWN Laws of Calfforrr4" Contractor's homy w sub- <br /> eentracthng Soyytuh0 oetti[rea tt+e 1pttod�fiy T oMr1y.that Jn me perfirmo of nrw work for wrutA 00 pea W rs J&$w 1 sharl employ persaru 8Waj9Gt to <br /> VYORICFRS 5gT1t7N L,arrs al CaFlbmla <br /> APRL Mt,JST CALL 48 wOR mG HRS 1N A]PvAw�C[�F I;dk ALL REQUIRED INSPECTIONS_ <br /> /� Ttin J►off^=" ��,t .Aate e f 9. <br /> 5pn hr G <br /> SEE SITE IN UNIT IV WORK PLAN DATED: <br /> DEPARTb100 LOSE ONLY O 7 s <br /> APghCathon Accepted BY Date 133ved /O Ste! Arca <br /> Grauv insyecean By Gale„ Ghnat lr4paraon By Date_ <br /> Deatrucoen ins"an 6 t} <br /> CONIFA H SrCONOnIONS <br /> ACCOuKnNC ONLY svOq <br /> PE GOl7E5 FEf liiFO AMOUNT REMF TED CNECK s RE'C'D BY RAYE PERM"r seltviGE REQUEST 0 INVOICE <br /> 35'u� B'9 8"`/ r 7�o G� i S o 3 <br /> C5T IZCvEN$FD CONTRACYOI 5i5J r- (Y i4 LYC�S;E 8tWOR COMEPENSATIDRT D]rCLARA7ION <br /> VNZT N-5/Z 3/49/sign~Mr TOTAL P-02 <br /> 0 Post-It"Fax dote 7571 este j -$'y pagBr <br /> Co r0ept <br /> ,.r t <br /> Phone M Phone a <br /> Fax r Fax k <br />