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SFN BY: S�-'ECiFUd tXJLJFAi1U'4; <br /> a _ <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> ✓� SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES- <br /> ENVIRONMENTAL HEALTH DIVISION (PHS•EHP). <br /> ✓all+ 304 E. Weber, Third Floor, Stockton, CA., 9526i­* -' <br /> (209) 468-3449 FILE COPY <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM RATE 13*UIU <br /> Apprc,tion in hereby ntadc to Si w JUJyWn Goint,iot a permit to Ccrlstfuci anvw install the worK ce9enbed. This appliCelt:Or r5 rtt34r. ut r•Orn};!rtinc.r•ern <br /> t,an.Ic3�wn t:nunly n<valirpmenr Tlrl?,GhnpiAr? 1115 ann t^p$tdrdarr~c r5`j;}n J:111LIM COUMI PUDIit;tt_alttt SNrv:es. En:•vo�^.:enta;Fa3!th Gr,rs;C <br /> s-c�C}5 TvN o A t s"'r <br /> 3`pl w. Cfk�Q"� �` •e_u ?S/v0 <br /> WELL Location �---------_.._._�_— Gress..L .............__._. <br /> PRUNERTY L7w'ie.RLC_'r4146zz PH150-3011/ !n•7cr_us/q5RN_ Gk1RNlc�i7� .:rtyST `\) 7,F` �IS' rh nc -._..__.. <br /> ._ ..... <br /> Lwt�w�L �� v� �b5 5ta�f,8 465 _g-It <br /> C-57 Cenirac!orS�rRU r XP AJnrc s°� ' r''ysY`T0 �'• ---t cJ+ t„ro:,efi.._ <br /> __.._.._.....___....... .. .... .. <br /> Gonsultantr'St t Ccntncia! Q'�`vD? y�.oYScSncaresst`Ilt( Mor=r S�_ L.r}_�S`Cac-o.J t RG 5b23��.,cnea$3$=`r4$$ <br /> GLS ............. _... T r.'rrn,ha:, R.irre `ec!. a,.__••.____..__-. <br /> tArORK TO BE PERFORMED <br /> Nti1ti WELT_i Qf_tRINr:(t:'r L,C;Eit<ssrc)L?E.}iYC!Ri!'!_NCI,,IiANC'-A�.;E4 OTHER') Q CF5Ti+'.k.—, ,N ,r I, :e tyre ue!,, <br /> I1 50:1.2ORING* _ Q -)VFR-GORE <br /> /JE1.L.'J, MW1 MW.Z M W3' Ij PRES--URL C kKOL-' <br /> --------..._._..._.......... <br /> ..................._ _.......__... _...- - - -- -------- ._ <br /> COMMEN-S- <br /> TYPE OF WELL LNSTALLATIOh TYPE COf4STRUCTICN SPFCtFICATiONS tt <br /> $,U <br /> 01IITC•RIt`.'•G '--­CJLLGW S rE:,v UTA UI. 61_AR_H0LE .H `--MUL'tPLE CAZINGS?Q YES �<Vi, Ai, LL CASINO il!J --- -- <br /> 7 EX rRAC7 I)N Q AIR F-AMMF.F.!DR-VE!N C:AS!NG THICKNESS_�•L�Z-'1O TYPE OF CASiNt i "fi: <br /> Q VF,POP. Q MUD ROTARY OEP-H OF GROUT Er\L_ R IkLWIE'TYPE )_ 3E USEL XALI(,Li. <br /> Q AIR SPAROF Q Pi1.SH POINT c;Itr';tJY.5EAL PUfr!f't Q'f c' 9 Nu (NOTE: MAXIMUM FREE-FALL DEPTH iS 3G') <br /> Q SOIL BORING Q HAND AUC-ER AFFI' Q)( t3?NlLIr3 Utfttl— �f30L.TF.D TFiAFP't;fs::X nr Q,Tr�E N=E <br /> OOTHER: QQTHER ---....__.._. CUNUU%rOHCAS'.NUi'iLgF'C)8'cD'-OJo--LrfYES GStspec:•`i^.1U:r I+c.e:---- --- <br /> .. ....... <br /> COMMENTS' —... ------ <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I herwoy certify That I hale prpairad th;s a;.phratror-,tnd that Ma w,rk jwd to none:n acc)rdance w:[n San.1caq::rn County Otca-u-i_as Stale Laws,and Rule* <br /> ani 4egulluons of Ino San.loaqu.,n Co-ant's tlomeowrior ur acar,saa agent y slurrat_jre::ertrtre;the fv1;clwng "I certify that In the perforttance or:he work <br /> for wh!ch this permit is issued,f snail not errrpruy persorrs subject le WORK S'C0UPENSATTON Lawn ofCallforniam<ti!s MIrrig or s•,C- <br /> contmct:nc signature certifies the fo!1z vinq 'I rer'rfrr rhst ir. (hr f.rrf.:rr stn(..of rhd wp.h for rnp+ch this Fruit is i3stn;.1.!..1rar:errpA;?-prrr:;onr;NuOi-ct <br /> WORKERS'CobrP °ATIOti'Lows of Rifuivia <br /> T EAP=LICANTMjd9T.0 Q dCIRKiNC NRS IN ADVANCE FOR ALL REQUIRED INSPEC IONS. <br /> 70e, RC 502o�t� /0 3 Signodx -- ..—._._..._.__..........._ C�Q <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED: icy 13 4c? ✓_� <br /> DEPARTMENT USE ONLY <br /> Appliceton Acceptr-d By_ U 'e lasurd r/ <br /> _...__._......-_._.._......... _ �.......-- - - <br /> Groat Inspecti3n By--- —-- -............:......- .n.,tr....._._... ---- F,r.al Inspa-clicn By ---- __.Date............. <br /> . <br /> Destruction Inspection By 1Tttto <br /> COMMENTS I CONDITIONS. <br /> ACCOL'MTIAJG ONLYAID4 I C <br /> PEC OIIES I <br /> FEE INFO AMOUN, REMt'rrFf3 I CHECK to ; REC'D BY DATE PERMIT I SERVICE REOUEST a i INVOICE j <br /> C-57:LICENSED CONiTRAC TOR:MI UST SIGN UCEINSE&WCOR KIERS'_C0mPU4Sk TION DECLARATI40N <br /> UNIT IV.6)23199/sign bkpgfMT <br />