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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., 93202 <br />(209) 468-3449 <br />M04 REFUNDARL5 PERIViT EXPIRE$'! YEAR FRt3M DATE ISSUED <br />Application is hereby made to San J02gd n COLrty fat a peir7,t to construct andlor Ir SWI the work dedesdibed This applt^atlzr+'s mace .n :4-opliance wtrr <br />SaA Joaquin County Development Tithe/ Cnap.er 9 1115 3 and the Staroards of San,}aaqUIP C'ourt'/ Publio Healith Services, Enrlronmental Hea 1` Dnrisfv' <br />WELL Lavation �p( �Qt'ez'r 1-#4. Crass Street � Pfzx.% ..-i Gty Zip �3r� Pu eta► Assessors <br />PROPERTY Owner �dlt�d�: �Fcl4ress 1rK (�Mt 0t,� �.-City Zip �S?. G -,htne# <br />C-57 Contractor 6 v i iM rea3� 'i i ems! S1 f a�GG _ ,C t/ 7,0 i rr- Lfc#,I 396 Pana# 1 <br />Consultant lSuS Co -tractor f Addre13141*4 <br />2-H 0 aur <br />GIS Cvordln-.IQS )CTownship Range section <br />)NOW TO BE PERFORMED <br />�iEVI WELL I lTl^ CPT, EOPRO HYDROPUNCH, H D -^USER, OTHER') p OESTRUCTION tchacse type baio�} <br />/ L. ORNG# �' a OVER -SOBS <br />0 WELL !t ti PRESSURE GROUT <br />'Other <br />COMN;FI,"CS <br />TYPE Cir NfELt INSTALLATION TYPE.06TRUCT13N S#sfiGaFl�Rs7l4ui5 <br />O dtONITCRING C HOLLOW STEL+4 DIA OF 60REH0LE i - MUL-tPLE CASINOS? 0 YES 0 NO WELL CASM3 MIA,_____ <br />D af7R4Cnom 0 All; HAMMFPJ0 WEN CASING THICKNESS 'YPE OF CASINO, a STEEL 13PVC 0 0THEFL_ <br />0 VAPOR 0 MuQ ROTARY DEOTH CF GROUT SEALREMIE TYPE TO BE USED, 0 AUGERS GriOSE <br />0 AIR SFARGE U PUSH POINT GROUT SEAL PUMPED a Year d NolNOTE MAXIMUM FRU-FALL DEPTH IS 310) <br />O BORIN3 j HAND A IE APPROX BORING DEPTH 0 BOLTED TRAIFFIC SCY or 0 STOVE PIPE <br />Q OTHER C 7HE o CONDUCTOR CASING PROPOSSC? (if YES Iist soscf1Ca,ons nore) <br />NOTE: OFFSITE BORINGS RMUIRE ACCESS OR ENCROACHMP-NT PERMITS <br />i hsreby terry hat 1 have pr-partd trva apt:icabon ar.0 *hat the Nort witl be dere �r aorard-1I1ae ukh San JOagUo Cpunty O inanca=, State Laxs, end Rules <br />and Roguta:ions of the San Jcagjtn Co;.'r'y NOmaor.rer or licensed agents srcreturc Cerfire4 the folbuilna 01 cartlfy that in the performance of the work <br />for which Ihl.s parmft,s issued, I shall not vmplay persorrst subject to 160ftKERS' CO1WPEN5ATlaNbaws of Calrfomle 11 Cell ravtOr's hiring cr:uh- <br />rontractrg aignat.ire c9rli'Ies Oe t+sliamn9 "I cc0y'hat rrt file perfcrmance cl We work fcr YA:;h &S ptrm 'IS issued I Shall enipto/ persons subyecf 10 <br />vvOR< RS' COMP6,%3A PON LaNa of C:aldarrra ' <br />THS APFLE AhE f UST CALL 48 WORKING HRS IN ADVAhICE �OR;{kl,f. REQLJIAF.D ENSLaEC7IgLl!+[5 <br />Signed x--� Ts'li--- r Sr Mats <br />SEI~ SITE MAP IN UNIT IV WORK PLAN DATE), <br />DEPARTMENT USE ONLY <br />Appli $iron Acceptec By „! _ Data issued �L �Anq L + <br />Grout inspection By Date Firsl Inspecaon By Dates_ <br />1Jest'ucton tnspechon 14 Dat* <br />COMMENTS 1 <br />LACCOMUNWING CHLY P,10# <br />is FEE INFO AMOUNT REMITTED CHECK# <br />oG` d5� Sar <br />C-5_7 �UCE�NSED C,0N RACTQA MST SIGN <br />"T IV - 6/23/59 /;Ian bkpg/Ml <br />REC'R 19Y L DATE PERMIT I SERVICE R1EQUES'! # INVOICE <br />41Z. Alb oa I cot, 6 C q <br />'MOAT DECLWTION <br />�� Z0 39Cd 2a17Q'Z� l-[J.�I.3 1=E�E8StrS1?� _ <br />ES'i;. 0@2Zf@�lb8 <br />