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WELL PERMIT APPLICATION FORM UNIT 1V <br /> SAN jOAQU,N COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA-, 95202 <br /> (209"463-3449 <br /> NON-RE=UNDABLE PERMIT E;P1P. S 7 YEAR FROM Ogre iSSiJED <br /> �:paiiC3Gort is nere5y nada;o San JC�CuIR Coun `ora it to construz-and/or rns'.zl:the work descibed. i nis application s made iR CWnlp. anoQ.wrt - <br /> ry F <br /> San Joaduin CauRry DevetopmernE Title, GCwip:er 9-t 115.3 ar>d the Stand&=of Sar+.ioaqu-L CowXy Public Health Services, Envirammel mal ;n <br /> c>lvfS;pL <br /> LL Locaton r Grant Street l n r Vh 'lp AAa a Qrs <br /> Q -�, Larnrn zD 5 5 <br /> PROISERTY Owntrr ..corona 1 'y' I �.i honey �0 u <br /> i <br /> Contra=or r r1 <br /> rAddr. c - Gity rip L 7d�0 1pnot1C93(707 <br /> Coruultartt Svb Can7a�or ATC A oCic c AOCr�,. (}5 y ! I •z* N 1 <br /> 1CooroiftrAv X Y TawnshiP T Range l L� Samson I U <br /> R)C O SE PF_gFoRM -- ---- - ._ <br /> 6W WELL!SaRING(CPT,GF-OPRQ$E.I4YDRoiausicm.HAM:; Auwp_OTwaw) Q UG <br /> OESTRTI0N(cnogse type below) <br /> SOIL BORING a n OVER-BORE <br /> 'Other., wa-LL d AA Q PRESSURE GROLrr <br /> .MENTS: <br /> _OF WELL 1 TALLATiON E CONMUCnON SPEC SCAT 2NS <br /> NITORING HOLLOW s'-M Out OF r3GREkOLE r MUL 11PL E CASINGS?Q YES NO WELL CASING DIA; <br /> #?Ar <br /> ;T10N rJ AIR i-AW lERidRNEN CASING THICKNESS TYPl;OF CASING: <br /> 1] a MUD ROTARY neFT'rl OP cLRouT SEAL Q FVC Q D+kEr�. <br /> GE �=•� TRl m,F-TYPE TO BE �AIIGERS 131-IOSE <br /> a PUSH POINT GROUT SEAL PUMPED: p Yca a No {NOTE: MAXIMUM, Fr"ZE)w-SAL L fl�PTH IS 3�') <br /> {]501E BORING Q HAND AUGi APPROX. BORING 7EPT1-! BOLTED TfZAFFIC BOX or a S S 01IE PIPE <br /> '7 i1.lR r 4Tl;5rZ CONDUCTOR G+S1NG 1?R4POSED?��- YES.fist W*Q_,, tiaaS har&): <br /> :OMJVISws" LQ - / Q <br /> f <br /> NOTENOTEe OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> 3ertay t: dfy that i have pes;wred tht5 a0plic9ttpr Dnd Mat me work will bo Cone in�ccgraencC with San Joaquin County Ordinate K;tv L:WS.and Rules <br /> rnd Regulationx Of the San Joaquin County. Momeowner or iicnsed ager:s sign wlwre certified the following -r cermy Mae in me aerbM12+7ce of the worry <br /> hlch obis Perrrtir is issued,!s%Wj oar mrrpleypeersoaS subject to W0PJCF-FIS'COMP1:NSC770M LewS of CalJfoMia.' Contras Airing ar 9uo- <br />-o ctrrtg signature oerifir ttte fOrfawtng: "1 cerriry thw;n the Pa�ormanae of the wortr fOr anhicn t)4'Ofmit is is-SOW. l shall eftwioy persons subject to <br /> 'vVRK6);?S'COA6PEAr$AT70jvLa olCaft"W ,- <br /> THE A?f' ANT MUST CALL 49 HRS 1N ADVANCE FOR ALL REQUIRED 1NSPEC"i'IGNS. <br /> SEE SITE MAP IN UNIT EV WORK PLAN DATED <br /> DEPARTMENT USE ONLY <br /> 1600,Accepted ay Owe issued - <br /> .-�_ .��....---� Arta_ Q�Sz,_ <br /> rout Inspection By Qats Firfei Jnao=On Sy <br />*=foil inspection By - Date _pate -„ . �� <br />�l1�EM5/caNtslTloNs: —..°° <br /> 1 N-nKG ONLY; AID. FAQ <br />'E FEE INFO AMO1.JNT REMITT-cD MEC CASH RECOVE0 BY u ra PSRMITfSERY1GE REQUEST NUMBERINVOICE <br /> 3C a -;"-20 1 fob C>�D 7�b <br /> IICHNSED CONTRACT0R MUST SIGN 7ICrcZVSE.&-WORICE S'COMPENSATION DECI-Ay FON <br />?;T IV-b/23/99/s�gr,bkpa/MT <br />