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ren Uta UU ue: jup brenaa ! inael i i i'Ub 4bt-I3 r7j P. :3 <br /> 48/02 '00 TUE 13`43 F-11 1---7,9469968 ER-MWEST WC X1002 <br /> • I <br /> WELL PERMIT APPLICATIOJ9 FORM UNIT IV <br /> SAN JOAl COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DNlBION(PHS-EHD) <br /> 304 E Weber, Third Floor, Stockton, OA., 96'202 <br /> (209)468-3449 <br /> ) fW1U11I1QAli1lPty EXPIRES tffARS Mo MMM111.11111110 <br /> Appl;Gat'on is heraby made to Son Joequirt County for a permit to construct andlor knato)I the wallit desaillbed. This 8PP11caiian is trade in compliance with <br /> San Joaquin C4umly Oevetopdtent Tide,Chapter 9-1115 3 ane ft Stsndaids of San Joaquin County Public Health Sarviess.Envkcnr mnW Heatlh Division. <br /> WELL Locwoe,_ Ar seraat cur AKIL!_ ►zip-pallifiets <br /> PROPERTY Ownerelit—1 b5 4,il %1'2'or Hi ghm ST. �__1q City_7�K rtiti�c jP �D PRorn r + r ! - /31 7 <br /> C,87Contracta ,=µa+C u Tr!M� rens o is�� �C/l�r f �p ZiplyS�Llcllp_atp <br /> Conttdic .0 Sub Contactor F�1 Addreaa 1 7CiyI+W►rrraA.11lkf P!►One� !�'�� <br /> i� <br /> GIs;Coard'erates;x Y Towrwh- R•eee Section <br /> f T ; <br /> 0 NEW MLL!BORING(CPT,OE a ML��YDROPUNCH,HAND-AUGER.OTHER-) ''I )(DESTRUC ON�R�ty E horawr) <br /> a WELL A { 3PRESSURE GRD TT <br /> 'fltilen <br /> f COMMENTS: <br /> M CONITRWTill AFEC <br /> MONITORING It HOLLOW STEM OIA OF SORE1401.E MULF!I>.E CASINGS?BYES ONO WELL CASING 011k <br /> p D"ACTION a AIR HAMMERJDREVEN CASING THICKNESS _ TYPE OF CASING: a STEEL a.PVC 11 OTHER: <br /> gVAPOR a MUD ROTARY DEPTH OF OftOITT SEAL TREMIE TYPE TO BE USED: Rj AUGERSE <br /> a AIN SPARGE fl OINT PUSH PGROUT SEAL PUMPED: a Yea a XIM <br /> No (NOTE:MAXIMUM FRIM-FALL DEP'T14 130' <br /> a SOIL BORING a HAND AUGER APPROX.BORING DEPT1l BOLTS TRAFFIC BOX o: a STOVE PIPE <br /> a OTHER_ p OTMK CONDUCTORCASING PROPi18t D7 II (it Yres,lot spediftabons here): <br /> i{ <br /> ccraltt�tra: ruc-�F+1a► /o R:�.-,tir s. 5� Q , 'r' <br /> l <br /> CTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> at I have Fel this Wicstion end Meat the work will be done In ateomMnce with San Joaquilln lounty Ordiinani IMe Ls=,and Rutaa <br /> and Ftepalatlom of the San Joaquln County. Homeowner or Elosnsed april stnel rartl8es the fcilowinl"1 eel that in the pomfbillinumwe of fhe moody <br /> for whfch W3 Perrulrfs teamed,I ahtll not arrfrfoYpessorlsr svbJect to YW RKEPS'COMPENSAWN Laws of CtlAforr it Contn«.tor's hiring or sub- <br /> contrsmnp signatim cert@fes the fot minis 9 1 cer*ti 44 the psrfcrmeme of the wady for which moi pamlt fs issued,1 sha11 employ perwn3 subjecd to <br /> WDRKERS'CO~SA770N Lows of CoNamie.` <br /> _ 1011. <br /> ;' `. <br /> �i <br /> 5iprmd: Tltte Vlls i Was oc�®mac/'' <br /> I� <br /> SEE SITE Xp IN UNIT Ii/ WORK PLAN DATED;: <br /> WARTIIRIMIT Wet omy i <br /> Appgcil A=ptod By .�2��'� hate lesufadi // I0'> L o P <br /> Gran inspection BY Die ruilm Impedla,my Date <br /> Des"'O n Immgz Dairy li <br /> COMINEiM f ootttotr4m: <br /> �l <br /> ACCO>IM1NO ONLY: AM i it <br /> P!CODS FEEtwo AMOiw Raman CHECK*f9 - REC`0 BY I DATE PoitAT 1891111vill 7REQUEST a INVOICE <br /> f•n`-� �V r �� J[ i 1- 3/r ! l{ <br /> T r 6/231"li bhyy W- I} <br /> 1 <br /> IL x <br />