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Rpr 19 41 08: 32a WEfiTEX 191F-I.. 373-0548 p. 2 <br /> 04/19/2001 08:10 20946 J3 FIFTH FLaDR PAGE 02 <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> l <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL. HEALTH DIVISION (PHSZHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 952.02 <br /> (209)496-3449 j <br /> N -REFUNPAeLfi pfR.AI�r EXPIRES I Y LR DATE ISSUEd f <br /> Appllmtkn IS hereby mate to San Jaaquih ca:Cy Tor a permit ta.oanstruat andlor install the Wark descrlbad. This appllescen is made in cCnCS,anr a With <br /> San Joaquin County Development rite.Chapter 9-1115,3 and"5tandanis of San Joaquin Counry PuServices.Envizon <br /> mel Me <br /> dhn O'�visiort, <br /> VIELL Location ZQD Cross Street4att urn d'-Gly _ '_Parcet� <br /> PROPERTY <br /> Rr:a fllon� lnlcs - —Address .b. a�R R31-7 _ city L zpgS9 1 Phanew_ <br /> Owhe�„ <br /> C•Sf Contractor i�fln�}ra , .AddresS !° C°j <br /> I � <br /> 5 � <br /> Gonsuttant/Sul)CntadorS}rtit AddresDZ <br /> GIS Coonnnates:X <br /> Y _.. TRywrrt+hl�,__-- Rance 9eclivn <br /> WORT{ O BE PERPOkms0 <br /> � -• 1Z pESTRU:TION(choose r/fie beiawl <br /> *EW WELL)BORPIG(GPxQ SOILOROS G DROPUNCH,HAND-AUGER,OTHER-} C(cho BARE <br /> VSfELL I b 11 aRESSURE GROUT <br /> 'Other. <br /> COMMENTS: <br /> TYPE OF WELL ttSSTA T6ON TYPE GOlJS1RUCTIOtI SPECIFICATIONS <br /> M6PlITOP.tNG Hptt.Otril STe;'J DIA.OF 5OREHOLE<—fQ-_- MULTIpLe CASINGS?a YES p NQ VIlELt CASING DSA:�x <br /> a EXTRACTION Q AtR HAMMERfORWEN CASING THICKNES$,N'V' TYPE aF t;ASIf IG: ❑STEEt ` PVC �OTN.R: <br /> O VAPOR U MUO ROTARY DEPTti QF GROUT SEAL; _TREM19 TYPE TO 9E USED;U AUGERS LOSE <br /> XIMUM <br /> DEPTH IS <br /> AIR SPARGE EjPUSH POINT Gtgt)U7 5=at PUMPED: es 0 No (NOTE. OL EOTRAFF C BO% or LB STOVE PIPE a,} <br /> D SOIL 8OP,ING fl HANG AGGER APPROX.SOFt1NG OEP H <br /> Q OTME 07>ieR�� COntDUCTOR CASING PROPOSE]7-.,, tit YES.l IST aP"16cations <br /> COMMENTS: <br /> NOTE: pI=F51"rE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS I <br /> I hereby cert�y that t ha++e pfcpared this appFatltrn and thaithe Werk uAll tM done in acaerdanao with San Joaquin Cavity Qrdlnances,Stats L¢+rs,and Rule <br /> and Rs9ulatlanS at OC San Joaquin CaumY. }larrtgowrrer cr];tens �t to VIORKFRS'COMPENSAroOM taws of CafiJc AM.�Contrador's)*4"t9 ar Sub r: <br /> for which this permit is lJsrrcd,I shall not employ persorrs subj ons subject to <br /> epRttraCting sigealore eertiRes she lollowing:"i ce4;fY tRar;rt rhrt per O'rrrartce of the 44Grff larWhic 5 thls,aarinrt is issued 1 shag emAlaY) <br /> Wt]P.KERS-�MpEnIS t7lDN laws of CaGlprnia•" <br /> CAU- PECTOR 48 WORKING HRS <br /> IiE HIT 1V IN IN ADVANCE FOR ALL REQUIRED 1RESPEG MONS. <br /> 5i9ner9 x c <br /> 't't:IcrC.c4+DanY SSP-h7'�S E-r✓+�. �'~KL ,err t.,±•��7�(ot. RE.✓ <br /> print Panet AY' Y'•�a�" .''�'=v:v'FF,;Ye,�'�:-:r••, <br /> SE =":�1T MJoip ;Ihi,;�t1NlT`;lva <br /> ­ RK„ PAh. <br /> DEPARTMENT USE ONLY <br /> l01ta Issued -- �--� <br /> AppIECaFw[I Acceptad 5Y_1Fflt� � - pa•e f <br /> Grout In$pcGtipn By Date_ Fie$Inspectlen 8y <br /> [7astrucfon Inspection 8y Date <br /> COMMUNTS 1CONOITIOINS' ' <br /> At.GL31lld'Tltrt3 ONLY: AtDtY I <br /> PE CODES FEE INFOAMDUtiT REAtI fTE GHEGK 0 RECO BY" DATE nRMtT l SERVICt;RE0UES7� INVOICE <br /> `A7 [ b Y oa p zZed �] <br /> Jt$t�t1d0 <br /> A16- <br /> 3 <br />