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' - - D0 D 1 1 At i ='P01P©l i r <br /> i <br /> r <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) 409-34�F O <br /> NON-REFUNDARL E PI^Ris1'%1T EXP,RES 1 )EAR FROM VATS ISSUED <br /> AppliQ?t�)n is nerebv made to San Joaquin Cot nt/for a permit to construct and/or rnsta`1 the work described This aophcation is made in compiiar)Ce with <br /> San Joaquin County Deve,opment Title Chapter 9 1115-s and the Standards of San Joaquin Coun*y Public Health SErvices Envuonmental Health Division <br /> Assessors <br /> ' WELL Locatio t_ oa ll 9 `I o_ss m I rF_ Cross Stree, PLAfLoW A`1ECrty MA t^f1`F_GA Z-p 2S3s31-oafetiv 92 ?- 2- 0-03 <br /> PRCP£RTY Cw-er fk t N E tAA R[� 01 L 1Ltw�_Addtr ss l O B -u S C,ty t1 K�'C .'.ip 9 Phe te# 4C �� <br /> VALIFY (200) <br /> c e7 CQiitrarto F 1 SG 4 F NV, Aoc'ress 39 S .f�1 tS_�3.AC�_erty SPIE t tGS z,p9,gs� L,t-#6$3V65 phurteg }l-2- 110 <br /> R R>riGi�0i�0 �'�916 <br /> ' Consulta9t 1 Sub Contrt,a'or R A In ASE il N y ___Address_ F 0 G I City *M UcGgf Phene#3 C4 <br /> Y Tor nsn p Range SEc'�ti <br /> ' ldQRY.TO�.lr FLRFQZRIED- -------'- --- � - <br /> I NEW WELL I BOR'NO(CPT, HYDPOP4hCH HAND AUGER OTHER', 0 DESTRUCTION(choose type below, <br /> SOIL S(aF N,- V-�1 ^ Fill rr_ (�OVER BORE <br /> Q L^YELL k i7 PRESSURE.GROJT <br /> col�nlrr:�v_ � If -6-it-Y, GEGtPili0( I; <br /> MRaMiRE OF WELL CONSTRUCTION TYPE_ CONSTRUCTION SPECIFICATIONS <br /> NITORING a HOLLOW ST9M DIA Qe SORE�DLE 7.'111 tAULTIPLE CAS,NGS?L YES I NO WELL CASING DIA 0A <br /> Q EXTRACTION 0 AIR HAMMER!DRI`dEN CASING TH CKNESS W A TYPE OF CASING p STEEL 0 PVC 0 OTHER 14A <br /> ' Q ,/A-0k 1] MUD ROTAR' DEPTH Cc ar OUT SEAL 'S E Y _ TREI'AlE TYPE TO FE USED a AUGERS 1HCSE <br /> Q AIR SPARGE j PUSH POINT GROUT SEAL PUMPED 0 YAs III No (MOTE MAXIMUM FREE-FALL DEPTH IS 30) <br /> 0 SOIL BORING 0 HAND AUGER APPROX CORING D1EOTH Z5 -P h IE T1]BOLTED TRAFFIC 83X or p STOVE PIPE <br /> j OTHER __�i-r q P f 3 ---- CONOUCYOR CAS]fd�;PROP OSSDI) 140 ( if YES list speed cats,)ns here) ---_ - _ <br /> COMMS\TS <br /> bAlE0 ift,h'v' lt,, t X99. <br /> NOTE- OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITSI <br /> I heteby Centty that I nave prepareo this application and that the work tv,ll be done in accordance with San Joaquin Cat my Ordinances $tate LawS_, and Rules <br /> ,na Rfegulat,ons of the San Jo.iquin Count; Ho oi;wnzr or lrcPnsed agent s signature rertif es the f tfomng "1 cerbry thut in the performance of the work <br /> for which this permit Is issued, l shall not omploy persons se bject to WORKMAN'S COMPEYS.A TION Laws of Cslrforma Contractors hifino or sub <br /> „o•a,actmg signalve ce't,FCs the follovvinq i cortir, 'hal r?the per brmance of the work f7r which tnrs oermrt is rssaed I shall emeloypawna sjb)ect to <br /> Vd41eA ANS COIL `caws of Cehforr a <br /> THE APPLICANT MIJ.,U�CALL 48 I'RS IN ADVANCE FOR ALL REQUIRED INSPECTIONS <br /> gned x_ '= <br /> SEE SITE MAP IN UN T I\! WORKPLAN DATED <br /> ' a/AILD <br /> ATMENT USE ONLYAppfr�ationAccepte,lBy � � ---Gate Issued—_312-����--_--Area- 3-0 <br /> 3��t Insp"ticn By- -_ _ _--- -- ------ _[?atp - Final Inspection BI <br /> 'nes ructwn In-paci.Dr By --�----- <br /> ME?JT7,+CON01710t4s <br /> ACCt,UNTING ONLY A]D# -- - - rACfr <br /> PE Cooes FEE INFO AMOUNT RErMITI ED GHECK#/CASH REC VED BY DATE PERMITiSERVICE REQUEST NUMBEP INVOICE <br /> X50 1 --- - - 00 - 54 5 119sR# ( ZG 3 <br />