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FROM IWRTER DEVELOPMENT • 916 662 1592 1902-08 10132 #877 P.04/OS <br /> 10-18-1 W9 2:02PH FROM P.2 <br /> WELL PERMIT APPLICATION FORM UNIT N <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS.EHD) <br /> 304 E.Weber, Third Floor, Stockton, CA.,85202 <br /> ROO)468-3449 <br /> NON-REFUNRASO PERMIT EXPIRES 1 TFAR FNM DATE ISSUED <br /> AppkAw I5 bMty made to San Joequin County for a pdgNl to construct arxVur InaleII the work daeabsd. Tiva eppliouian Is made In compflanwwith <br /> San Joaquin County Dgwi pment Tlva,Chapter 41115.3 and Ino Slandarda dl San Jeaduin Ceuny Au6lb IteaN SMJM,EnV1Mnmentel Haeeh Dlvieen. <br /> g /) AeaaeeGr'a <br /> MViLLLAcaOon 7I=Tf?f!q &e Clots Stmct L/'13.Yy(7�CKy r 10 =�2�ar"w <br /> �� s, bests m� <br /> PROPERTY Dw=r Fac.�1371`[) yyo�•- A� fL Gky� ZIP p4Pnona✓1 <br /> cal conva:ia l�luteu- fL� nc. cM zq�tidt_��hona <br /> ConsuharAl Sub Cortmotoc (/_.Oh�j I � Address�d� .bl/ P�Ur cry / ienr` Phoney 9/bI2 <br /> Ota Goordo-Ams:X ,Y Taarwhip �•s Rang_ G Sectgn `3 <br /> MMEK TO Bs p1m)AMI <br /> Q NEWWrLL i BORING(CP ,GEOPHQBE-HYDRDPUNCH,141NOWUOEi,OTHER-) E9TPUCT t (yrovaa type 1 } <br /> n SOIL BORIN30 „ PVER a0Ve <br /> O WELL _-„ ✓ p f� - RESSURRO OUT <br /> C)MMENTS: <br /> ETTQFTIT F`L INSTALLATION TYPL- cooiSTKU -_UQ 17 <br /> P MONITORING LLOIN 5)Eh7 OIA.OF SOREHOLE�_MULTIPLE CASINGS?p YES rO WELL CASING OIA:� <br /> 0FXI'KACTION OAIR 440M6it0,RIVEN CASINOfT110N[SS TYPEOFG48WR: QSYRaL pvC OOTnER, <br /> a VAPOR O MUU RWARY DEPTH OF GROUT SE 0 TREMIE TYPE TO BE USED, Q AUGERS QHOSE <br /> Q AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Vac o (NOTE! MAXIMUM FREE-CALL DEPTH IS 30') <br /> Q SOIL BORING 0 HAND AUGER APPROX.BORING DEPTH - 0 ROLT6D TRAFFIO BOX or 0 STOVE PIPE <br /> <THERd�u a1N aljp OTHER CONOUCTOR CASING PROPOSED7„j[Q,_(If YM.I V dWfk-MW a here} <br /> I 'JBP/Y �iCtyp'ir�-1✓Y <br /> Ilk <br /> OOW�,,I�AlNTE: y ✓ !� 3'v'L <br /> NOTE: FFSITE OBORINGS REQUIRE ACCESS OR NCROACHMENT PERMITS <br /> I hero*artily thug I have psaaaridthis000tI and 1 al a work will fK ddrce m a=rdanm whh Sen Joaqu GgGoUrq OrOlniMxM,3Talg haws,entl kolas <br /> and RtpuNUww oI the San Jeaquln County. Nomapwnar er aaneaB apeng'a dQnaWm eorufitre tM taQOMry:'l cstlfy UNrin fha peAormar,ca alNa»txA <br /> Ia which this pe+mrYis;am.ed,IshnU not envoypensone suhidet he WORKERS'CONPENSA77001 Laws of WflomhO Contmciar'ohiringorWh- <br /> aontrwirpmonoturecMlffea the fobwvlp:TctyPdyN infheperlonrmndddfM Parkla wATlr gAtd pdRnif ra i9auea,1nnoN empky peradna avbbtt>D <br /> WORKERS'C13V ATyON LAwa or CPN <br /> T LIUS 8Y1/QRI INGHRSIN'A6VAEE 'r Jt <br /> NCEFORALLREQUIREDINSFI /�y/(�{NS- <br /> signedK ""• Yale ; <br /> LM,�/�Deln <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED` <br /> DEPARTIMINT USE ONLY <br /> Appli aGn AcWPW 9y— J� -dN hWG 0 Af.B LU/W/ Q G 3 <br /> (Lout Ihapeeddn IN' Dao¢ Ferl apapecdon By ante <br /> Demucbon IrrtPmdon By Dope . <br /> COMMENTS f CONDITION Ct <br /> ACCOUNTING ONLY: AIRY <br /> PECOOES FE61NF0 Amouhrr mirm CHICK/ RECO BY OATS PENMIT 1111111 REQUesy a INVOICE <br /> C-52'UCENSED CONTRAGT%.3JL.LS7ST SIGNI-ICIIVSE 8iWO .MPENSA-110N DECLARAITON <br /> UNIT TV•e7234/mgn blrpg7MT <br /> E iE #!Z69i E99 916 -1VN0I1VNN31All NVIU621: AV2:8 • 0 -8 -ZI' V0 "eJ7e5-8T6ZZ869T6:A9 IN39 <br />