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WELL PERMIT APPLICATION FORM <br /> UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION ("PHS-EHDn) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3450 <br /> ON-REFUNDABLE P01MIT EXPIRI=S 7 YEAR FROM DATE 15to 3U1;D <br /> This 2pp6mticn is <br /> e in <br /> 119AM with <br /> Appll=Wn as hereby made to San Joaauit County for t5�and the <br /> cans res of San Joaquin County Por install the work s u��lealth Sem ees Enviradnmentai Hea Dhvi:Pon. <br /> San Joaqum County Developmeht Tdle,Chapter Assessods <br /> ''II yy� ( 1� Parcels <br /> �7� //IL1inaCnossStnxt/IVn,n.ST4y�CCLei�_ Y <br /> WEL'.I.oeador:�, 0' <br /> PROPERTY Owner 13 <br /> C•57 Cordra=r <br /> . <br /> consultant I Sub Contractor <br /> teas r GtY O�kl� �.._ _>shonest���yZd <br /> rl $ 7pwnsts,p Ran4e� — Sector <br /> GIS C ardmates:X . �• !� Y <br /> i <br /> WORK 10 6E PeRFORtMED <br /> p R'] DESTRUCTION(clsoose type below) <br /> FJ. � <br /> �AIE1N WL I BORING(CPT GEOPROBE.HYDROPUNCH "AND-AUGER OTHEa OVER-BORE <br /> 13 SOIL BORING C a PRESSURE GROUT <br /> L]WELL s <br /> ,Other <br /> �OMM>=NTS <br /> wPE! O� F WELL CONSTRUCTION"�YpE GONSTRt1CTtON SPECIFICA710N5 p <br /> atONMOR1NG >iOLLOW STEM DIA.OF g -E-HOLE <br /> ._MULTIPI.P CASINGS? YES p NO WELL CASING 131A�__ <br /> RAON AIR MAMMI RCRIVEN CASING 7HICKNMS`} TYPS Of:CASING fl STEEL g PVE a OTHm <br /> RCTIp mUD ROTARY DEPTH OF GROUT SEAL d TREiMIS Type TO BE USED VAUGERS pHOSe <br /> W VAPOR p AIR SPARGE Q PUSH POINT GROUT SEAL PUMPED es a No (NOTE: MAXIMUM FREE-FALL. DEPTH IS 30`) <br /> HANt?AUGER APPROX BORING DEP5 TH �BOLTI:E3 TRAFFIC Sax or t] E PI <br /> STOVP. <br /> jI SOIL BORING 0 s <br /> o 7 , et eec alcations here) <br /> �:ITHlWR coNaavC Car<r.AstNc s�oPos�� !tlof YES G <br /> COMMENTS. <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITSI <br /> 1 tYrCby CCris>y trot I have p4Dare4 LhtS anPniC3iior and tri!the wom win be cam In acwrnance wilt S94 JOaguun County Orduranoas.state LAWS,and RU105 <br /> Homeownef or Incensed agent's sgnaturr Carufies the to"""g."I�rY ghat fn the performar7ce efha work <br /> Re $LtVea to <br /> and gulattons of the San Joaquin County _ns 1vOR/UllAH S COMP�ATIOM Laws of CadfomO" Contractors Ming or sub- <br /> for which this permit is isSu0cL!shaft not t mP !nc rhe of we Oct*!or�.nfaM els Aem►it u rsse+ed.1 sRaIQ emFVeY psfsons sunlear to <br /> Conuactitsg ygnanue aeRrfies the fobawing: <br /> WOW(&WS COMPENSIt77ON LAWS Of w/off" <br /> THE APPLICANT MUST CALL 48 MRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Mite <br /> Signed x <br /> SEE SITE PIN UNIT IV WORK PLAN. DATED L7-0 <br /> oWARnIENT USE oNI.Y <br /> �j 'late Issued_ <br /> Apprmation Aompted eY rr — O F>1a3 Inspectson By <br /> Grout ftoec ion BY <br /> 'lesttu non lnspectlon BY ' Date <br /> GDMMEn?a r -Z lilt I <br /> FACa <br /> rzo <br /> 4—:: <br /> NLY, AID# <br /> 'r FO AMOUNT REMITTED CIiECK1IGASH ! REC,IrNED BY DATE PERMITISERVICE REQUEST NUMBER INVOICS <br /> 1 y <br />