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S_N` 8": 80ECTFUM EKPLOF.ATICN; , = 21 99 14:36, 2094658773 -> 209 838 9883; 41
<br /> WELL PERMIT APPLICATION FORM UNIT IV
<br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES
<br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD)
<br /> 304 E. Weber, Third Floor, Stockton, CA., 95202
<br /> (209) 468-3449
<br /> 14ON-REFVNDABLE PERMST EXPIRES 1 Y AR FROM DALCI y"
<br /> Apprc,Sian iT�hereby niadt to Srni Juayvm 0oJniy fGt d p('rrnit to CCnslfu;t and,o, instalt the work Cc6enbed This appircal.on is in r;wrlpile1we wim
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<br /> WELL Location_ d...,��w _.r—_Gr'ess ;trees TTJYLi�Y1_�CNv-_ �-'CI�• , -1.'�,, �`IZ f•:arr.,Mtx-� J�
<br /> Q , SO` .""77T"RTTT�Y� lr �y/��� hpi��•y (�-e.&63.77. �/ ^' 7
<br /> FRUPERTY Uw14'_ .1t=r5 (L !ldorecs �.�f.}~ �4-. J P. lJ^'"+-"' 11�`rtr'W-.../, /
<br /> C-57 t;c>rtlrtrc!or (•``_���,``'�����llllll ...,v_,,,�`�_._
<br /> Consultant!St.b C�tiF(n�trca�civr_� Coy ca _q ion.,
<br /> GIS CGCrd ralt,s.x Y I r�wnsh!�, N t�irna eC!t:t D
<br /> VAIp!!t T4 BE PERFORIWCD
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<br /> `I Ct I IS�eCLP OTHER,) a DF;7P!.1(;"rj()V ['Ir6i se typ a eaElo,4;
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<br /> rJE.l1-# PRF»aktlFtf_ C3RO L;l'
<br /> COMMENTS-
<br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPcCIF CA IONS
<br /> tJ10;11T RIt!G —q l3LLC1tN S tkbl DIA til 13LrHLk4uL 4d0..$ n1U«71I'I.,f.CASINGS Yc�rNu ;M1f i,l CASING UTA� .Z
<br /> '}FX�RkC''li7t<I /Q AIR FAFlIL1FRlr}R'VECr° is hS:Ncy fHICi NEriSs[tt-�_ TYPI OF CASWC, 11S I t-i i. +��i: nj t7THF R
<br /> U VAPOR q MOD ROTARY f)Er"ti DFL GROW* 5f 1. IH MlE'SYPE rL 3E USE[ �f.UI:ERS P[-
<br /> 4 AlP SPAR61Fp r'tJ.sri P(')iNT c;ticiu $EAL PLJUPti; V-fev 0 Nu (NOTE: MAXIMUM FREE-FALL DEPTH IS 301)
<br /> XSOiL 1509C-CM-5 o t1AN0 At1C ER AI'PKC{ x. OURING ULf 1rt `W-- 00....... . j(B0j.TP0.HAr F c;Rc7x t,)r Q 1,TCA'E PIPE
<br /> OTHER. (j OTNLR __. ...__... C:U JfjtJU TOP CF.ti'NC4 Yh'l!ItC)5FI7�.._IQ!of YES.list,per:h sat pr)s hr.ic
<br /> La_. Q11. 0.1e- ----
<br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS -
<br /> i-aarrany cortify that I ha ja;,:wsaa rRd th;.:appl!rnhon Land that ttiR wcvk wi.l hc-Ione in 7775ance w;th Sart icaqu'In CJJiaty Cham 2'i_r!s tit,a,a!L aws, rtgd Rwe6
<br /> ant kCgJl3tre15 olm&San Joaquin uounty t'1An',GUwn;ar ut licpnsrad aLewil s siyr<atu•e a.crti`tes the rPliowog "i certify fhal in tho pedorrnanc&of the work
<br /> f r wh!eh this permit is issued,/Snail not arr)i:loy parsons subject to WORKERS'COMPENSA77ON taws of California' -
<br /> cu,trect ne srgneturer cerirftes the fo!1zmr.g -i r.•err'trlr Neat ir.thr.�c•rfrlr>t,�ar>r:r of rhe oo!h fpr•whr,:-h rhrs pt-tmJ is r3sa.a:t.1, shat;�.r•.r',pir: inrrxn:rrt sljo/ cl rn
<br /> VdORr(ER�'.:Qh?FCNSA T70'4 L.)tvs o.Crlrfunrier'
<br /> THE APPLICANT MUST CALL 48 WORKING HR$IN ADVANCE FOR
<br /> �..-. _ ALL REQUIRED INSPECTIONS.
<br /> Sp � g.�I . // 7rSD�1e -. _QIA I
<br /> ...._.... ..... .....
<br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED:
<br /> c—J DEPARTMEN'Y USE ONLY 3s�j
<br /> Applin c.r,A.cepterl Ry� -- - ,F GU....` - yo . t}e'.r.I5St:r;Q ��yi ��� ----
<br /> GroJt Inspection Cay— ,, ��} D.,tr. r�" F;nAt InS:,n!icn Ca, f 'l.-,tr
<br /> hactruction Inspoc4ion By Itnt�
<br /> COMMENTS f CONDITIONS: ._..___..--._._.
<br /> A,COLaJT:PJG ONLY AIUrt
<br /> FE.CODES FEE II,FO AMOUNT REM-,FEL) � {:BECK a RECD BY PERMIT+SERVICE REQUES1 atNVOICE
<br /> 1
<br /> i
<br /> C-57 LICENSED CONTRACTOR MUST:SIGN, UCOENSE&WORKERS'COMPFNSKfION 0ECLARATIONT
<br /> Ij,'rT IV-6123/94 Js;gn bkpglill£
<br /> 1
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