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"-.1-tii`lJ"- W. =)WA 1 r'KUM .- <br /> WELL PERMIT APPLICATION FORM. UNIT IV � <br /> SA14 JOAQUIN CL)UNTY PUBLIC HEALTH SERVICES' ;: `i <br /> ENVIRONMENTAL HEALTHDIVISION {"PHS-EH£]"} <br /> 3-04t.1 Veb r, T`hirct Floor, Stockton, CA., 95202 <br /> -3460 <br /> 'NCila-f{ tiNDASLE'P Ft00 EXp1R S 4 MR,FROM DATE:�S+�it�Eb <br /> Avp6catiW is heteby nudc:w Sanjcapuin trournty/aa:a.petmd:t .v G ae llnr inaxau trier wort descridb*& This mppiieatnm is made in combiiance vv)' <br /> San Jcaguin county oe"wWrIer4 dw Chs trter 9.11.15.3 oho t.Ia.*StanoaI bt San:ioaaw"Loom pubIic Health Ssrvices,Envrronmentai meant!Oivmon. <br /> <; A�yess8r'S <br /> WELL Loaauan 15A�L� �r.1:. ic.1 g 4 c�. s o*t-$ttect:: coy= x p�a=,h .. ! 9:�' .�s-r f <br /> ;,.S7Conbac=or V_W;by_101yrA60 _; At0.es3:i�',C') _ �CltYQDSJ <br /> C+tYQ �,. <br /> F <br /> wcrtsuttant l 5vb Ganttactor � ' t J _A;dttiiss .�Y1�2¢ r�nZA 3 .C ' <br /> .ihS Coordinstex.:X `l T Rittge Section <br /> WORK TO BE PERFOR1YtEC7:,. <br /> -FW W,-ELL.!BORwo,(CPT,at SE.H7 F.)TtO. ritCH.ttAND-AiUGER.OTHER-) 0 C*STAUCTION(choose type beton!) <br /> a SOIL BORING t a OVERBORE <br /> za a PRE$$URE GROUT 1 <br /> •:that: . <br /> Y¢g OF WELL CONSTRUC770NZ:FE Cha ISTRUCnQN S?ECIFICATtONS �! <br /> IAONiTORING HOLLOW STEM DW OF'SOR,EHOL-c_.T--..hjULTIPLF-C +SING5?U YES ONO WELL CASING D <br /> EXTRACTION p AiR i-MMMEi�MRIVF-N CASING`THICKNESS ,YPE O caS»IG: p sFEt I}PVC 13OTHER. <br /> VAPOR (j MUD ROTARY DEPTH OF GROUT SEA`--- RF-MIE TYPE TO 3E UM: 0 AUGERS BHCSZ <br /> 3 AIR SPARGE PUSH;POINT GROUT seAL purApEp. a Yes a NC (NOTE. MAXIMUM FREE-FALL DEPTH IS 30') � <br /> p$OIL BORING a HAND AUGER APPROX.BORING Ela -- a BOLTED TRAFFIC BOX or U STOVE PIPE <br /> OTHER: CONDUCT Oft CASING PROPOSS07 (if YES,h5%apcc�cs„atiaos hurt) <br /> OMMENTS. <br /> NOTE. OFFSITE;BORINGS REOUIRE ACCESS OR ENCROACHMENT PERMITSI <br /> nereoy cef%4 mat I na-e areoareO this saOcaopn and that Itte.vo:tt with be Gone to ace woonc*with Sar+Joaquin County C#dusances,"Statt Laws,and Rures <br /> and Regulations of the San Joaquin County. Homeowner or i'=rtser3 agent`s signature oes f*s the fohkrwiN. It certhry that in me performance 4t the work <br /> .'or which this permit is issued.l SA011of srtMPtoy:pMonS subject to WORKMAK S COMPOVSA MN Laws of Cafflomia." Contractors 1U&- !Or situ- <br /> :ontraciing signature CeM fie3Jhi•f0110W0 :7 terW 041 in Ire P*dbm**Ce of the what*for carom Ws pen»it i#its#sd i Soo evnp1by pormys SirfljW.to <br /> vpFtichtAN S CCDM 7701V"vii q1: <br /> T,IE:APPUA �PTCA�LL 48 HRS Iii aQ;fANC Pt?R At-L FtGiflIRE !tttSPEGTiC3NS:. <br /> Si ? 1"dle4 I. .Ct <br /> 9 <br /> SEE SITE. SAP Ill UNIT IV WORK PLAN. DATED Qi? I 0 1 � <br /> �`.dEPI►117#fIBN1'USE ONLYpoplkaltt;on At:t,Septett 8ji. <br /> �l' .- . Maas lssureo4 / . Z t .-:�p C> <br /> f�� 7� <br /> Grout Instattor►8y Oats I:Ihls)Ittstlee xiorr$y..... Oate <br /> sestrucuon In"eetio Date <br /> COMM lCq+vDtTtt7rrs !ism M tt.3S es' is ' Alla-h <br /> FACS i <br /> ACCOUNTINQ ONLY, AMP <br /> t <br /> PE COUF-5 FEE INFO AMOUNT REIdITTED Ct{ECt{tgrrASH }ZCSIVIW 8`f LATE FERWTT1SF.WCE REQUEST NUMBER iN1+S71Cz <br /> Std t $ ` • S"t+ '/ ttD ` p - <br /> 171- <br />