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10/04/11701 14 4b ZV'd4bbJ4JJ r lr Irl r Luum U1 <br /> Post-Its Fax Note 7671 p@9esct P. <br /> ;no <br /> FromDFPI Cco 'PLICATION FORM UNl` IV <br /> 4 Phone 0 2_00)_ <br /> 3� L l IFaxR G ,VgLIC HEALTH SERVICES <br /> ,TH DIVISION ("PHS-EHD") <br /> 304 E Weber, Third Floor, Stockton, CA , 95202 <br /> (209) 468-3450 <br /> NPN-REFUNsJABLE PERMIT EXPIRES t YEAR FROM DATE=issUEO <br /> Appi,caaen s hereby made Ea San loaqu+n County for a permit to cortstrucz and/or,nstall•he work descr bed This appl+catton is made in compliance w+tn <br /> San Joaquin County Develoverient Ttle Chapter 9-1115 3 and the Standards of San JoaQu+n County Putsl+c Hsalth ServicXl; Environmental <br /> Health Division <br /> p L �'2'4 64'0 <br /> WELL Location 605 `%S PdC"I �C V� ergs:street Lo'r 'A�• city SAjbc4tb h P Parcem dg52i9 <br /> �I,� { c% 'I or�tS MO Si.. LY�'�QOIC�'8'r+ Zia Ptsane;~ <br /> PROPERTY Owners ;. S 1 AddressS03 � <br /> * <br /> C-57 Contractocm_c�_r�Ik%,% Pddress <br /> °Iso hom e. RkA• C:t.,N }�Vit 4-c'".S a L"AAS165Phone 4�5�31�'$�DA <br /> nsultantlSuoGontnctoM1 �4L��t��` S`�4lAdGrexSl2Q ��k► S " CityST"_"L+ _ Phanest 7D7 q35' sl <br /> Y ,7ownsttirp <br /> Range Szcuon <br /> GIS Coordij'Vcs X <br /> WORK TO E3E PfRFDF".hM1€D <br /> BDESTRUC TON(choose type oelow) <br /> �V!!WELL I BORING( CPT GEOPRO65 HYOROPU NCH HAND AllGER OTHER-) a OVER-80RE <br /> G S IL BORING 4 a PRESSURE GPOUT <br /> ELL 9- <br /> Other <br /> CC_�MIMEN7S ,2(i <br /> *N;TORING <br /> OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECEFICAYIONS `� WELL CASING DIA <br /> 81<01-LOW STEM DLA OF BOREHOLE _-.MULTIPLE CASINGS {J YES 'Lt^IO <br /> � STEEL VC 0 OVER <br /> EXTRACTION a AIR i�IANINIERJORIVEN CASING THICKNcSS SG�'4 0 TYPE Or CASING a � HOcE <br /> VAPOR <br /> r� 0 MUD ROTARY DEPTH OF GROUT SEAL �' 1 'Tr7jENI(E TYPE TO BE USED �UGERS a <br /> 0 A.R SPARGE a PUSH POINT GROUT SEAL PUMPED g'YN a [NSTMAXIMUM y6OED TTPjkFF C soX or a DEPTH <br /> IS 0•} <br /> PIPE <br /> STOVE <br /> BORING 0 HAND AUGER APPROX BORING DEPTH <br /> a OTHER CONDUCTOR CASING PROPOSED?__U (rryss list speuFcat.ons he•e) <br /> COMMENTS <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> e I-awS and Ruses <br /> I hereby cenit'y Lhet t have an re per,ints County appocaTion <br /> and <br /> tri-3t <br /> or tree Sed agent sds gnatu a cernfiess theone in 3oCord2nt__ t oSan`nga-1 Ce�;Yn�,d n rhe�rmanca of he wo k <br /> an] Regulations of the <br /> dor Regul this Ot the S ensued,!shah rro[a omoy nmf of persons subject;o WQR)CRtAN'S COMPENSATION Laws of Cif,/orn'a" contractors h,nrlg or stili <br /> for whjcl) signature certifies the I s)701u+g 'r CCfbfy mars the performancd c1 rhe worx for%wh+ch this parnR is Issued I Shai1 empfay Persons suoJect to <br /> contracunWORKMAN S COMPENSATION Laws of C9ht0mla <br /> AP Ll MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS <br /> Ttl e <br /> Sgned x_02 <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATE <br /> DEPARTMENT USE ONLY 1 <br /> . !.. Areas_ <br /> •R�,�,� Date Issued �+ `-' <br /> Appileat,on Accepted By �i - Date. <br /> n t3 <br /> Grout inspectioy <br /> Oaxe Final Inspection E(y <br /> Ce&tructlCn Inspection BY D7tC <br /> COMMENTS J CONDITLONS <br /> FAC <br /> ACCOUNTING ONLY AIDS <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK)rlCASH RECEIVED BY DATE <br /> PERMITlSERV10E REDUEST NUMBER INVOICE <br />