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5CIV: b': b-t�IhUrfl tXr'L.ihAiJ.i.�� y-!1•�_ 14:�bj �'!Ey(75tl//;3 �y _'Cy tlJb �ttlJ� �' <br />WEL _ PERMIT APPLICATION FGM 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 />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE 193UED <br />Appcic, tion it: hereby made to Spn Jingvct C3Jnty for <br />a permit to ccnalruct anWor install the work tiascnbed. Thls eppOcnt:or, is 013,1e in e.lrrlphJrli.r nrin <br />fan ,laalmn County nrJatnpmFnt Tin?. Chapt?r? 11 Ir-, 1 ann thr? SLrrrtarCc Cif San JOiCIwn COJnty Puplir: i'1_altlt Services Envrrunrnenta! HEa!th'.•;r, r':pr <br />L <br />WELL Locatlony � %h XP/ 5� <br />At,sessu, s <br />Cres. SL•ee! /i1 W AI S2' Gty .4e�jd% . L p,1��lit <br />PROPERTY <br />PROPERTY uwner!jJIRC�_._.._.-_._!laertsa2�lill.T%!�%�.._........C'!Y <br />r.%t ---`'p..ZJIAW-c ncnez --7.....__ . ........... .... .. .. <br />��L( ._/•(. <br />C•57r......... ... AJomm.-,aa.$A0i5. <br />Blom ...._.._..._._C:t•/ � i..iVFVKiJta �� X7__4..1 :7CM /Z�i. 351 <br />Consultant/ SLb Contractor o <br />_Acaress 17/1/ I>ti19/Ai75 <br />1,_Gl*yj&eow ..I :cam_ _..._.. PnOrtrtr&4�J _ <br />GIS Cocrd'ralos. x---- ----... - --.- ...... <br />c <br />� <br />_.... ..... -- - 1 <br />WDRK 70 8E PERFORMED <br />-1kIN'.. <br />tiff WELT C?f. GEc 096. 11YOROPUDJCH, HoN1:,-A1_;GEF1 OTHER') Q G'FFT,+'_1r;-1 ;.V ,.r.6�ac lyre a ton• <br />f}:r011 BORING � <br />�. ....... Q .-iVFR•RORE <br />Q aRESSUKL C. RRL - <br />CONIMEN-s- <br />TYFE OF WELL INSTALLATION TYPE_ <br />COtrST;UCTION SPECIFICATIONS <br />p MOUITGRIN'G p HOLLOW f; TLV. <br />DIA 01- BL�t;=1rOL6:....t rRtJL'rf LE C�SItiGs^ YE£ Q NG .tiL L LA!;I!NG <br />[I EATRAC Ii)N Q AIR. FAIJME14:OR-VEN <br />CA SING THICKNESSTYPE OF CASING Q S I I -r. L. p rvi: Q t?rt� <br />(] VAPOR Q Ml:ri P.GTi4RY <br />DE.? -H OF v70'JT SEA:-�— lFt(=h11E •TYPE 1-_ 86 U56G p ALk;bF:,v'r <br />Q AIR SPARGF IOUSH POINT <br />G11, 1.1'r SEAL PUM+'t:; cs "Nu LNOTE: MAXIMUM FREE -FALL DEPTH IS JG') <br />,BOIL BORING Q HAND AUGER <br />/ Y!9;Vx US .IKIPIG UtF ?",IT ror Q ,TC': E Pi.cE <br />Q JTHER: Q OTHER —......_._. <br />CONDUC fOH CAS'.N% P►tOPC SED'-___-- (if YES lief spec:'rcan:rls ltc,e; -•-- - <br />COMtriF, NTS' -- --- <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br />I r.t:rpoy cranify that I have praoarwd th:r; apptualinr ane that tha wprk arl.1 ne none :n ac-C-x=nce w:tn San Jcagaan C,%wty Orama•r_as State Laws, and RUIE6 <br />;r1Z Regu101:0ns of tno Son J02qu.n L;a:,my Homcowmv ur ocor.ssC agent s swr;)tXa ;AarItles the toli0W11q "! ce.niry that in tho performance of rhe work <br />forwh!ch this permit is issued. /shall no; employ persons subject le WOP,KEP.S' COMPENSATION Laws eCalifornia ' C.?-llract-r s rl'rlg or ;•:L'- <br />convact.nc sicnature certifies the fo!being 'I rer'+f,(r0iw it the f.rrf:rr>r t:rce of ;he oc,h N•r,yh;,-t this prirmt is i3sc cd ! slrah.rr.}d„rprrr:;o;rs <br />VXPKERS' COIL PEN°a TO,v Lolvs of Cuhfu;rna ` <br />TP NT MUST ALL 4RK{NG }iR5 IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />CeoSiynodx --- ._._.._.....`.. kp.Lr- <br />SEE SITE MHP N UNIT IV WORK PLAN DATED: Noyerr ber (6 _(J 1 J <br />DEPARTMENT USE ONLY <br />Appliceton Accepted By I/L .r�� t^ _.._ ._._. _..___..... _ ...... ..... Dale- <br />Gro..t Inspection fay _--�� `�- n-tr. lz 9f %j _ Frr.al In rie-cticn By '-ta <br />DGGtrucnon Impaction By Int: <br />COMMENTS J CONDITIONS: <br />ACCOL•NTING ONLY AID# <br />PE CODES I FEE INFO AMOUNT REMITTED CHECK # i RECD EY DATE PE UESi A ? INVOICE ; <br />3T0( l l`e`i-cam VO aL 3 S i <br />C-57 ' :LTCENSED CONTRACTOR MUST SIGN. 10ENSE'&�`ORKERS':0 '' ATIO V <br />UNIT IV • 6/23199 !Sign bkpg/MI <br />