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Z: r T <br /> WELL PERMIT APPLICATION FORM UNIT I`+I <br /> • SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95242 kZ�\I <br /> (209) 463-3449 <br /> NCD4 RErUNDABLE PERt11T EE-PIKES 1 -FAR aR0rA E AI— ,SSUED <br /> �pplicauon 15 herany 'rade to San JoaC..in Ca.rr`l or a pes-rit to Car:;'rL.0 art!:'irs a.l the VCrK dZV;`-e-d iiia a-.pi=3t C s —.ac-2 Z ecr^r'lanGL <br /> San loagain County Dzreioprnent 7"e Crap a•8-.t S 3 and the SLa-icarts o'Sa- _'�aq jir Cou^ j PUo cc <br /> �sessw '� <br /> cross s`- +-1 c ti Jt✓k�`� z 9s�b ��•�� <br /> N ' t_ocation 17 S +r 1 <br /> [� .Tn<., Address97j1 t3t7�-t �,Ieltl C,f �l��k��1 zP �lSZG7 =�;reRZ�7-�SJ-7Z� <br /> oROPERTY Owner r iCV <br /> tya�.[r tf L zoo 95/1{ Lim 7 I T ^cre��j <br /> C-5?Ccrtrac`cr !� Ad..r..ss x <br /> �_ ) -r,•.'� r-�Addess �� ,i�� 5�-,1-T j� C.�i•��-+P�'I i_� o'^:-sv;-Sly �%-���6 <br /> Consultant/Sib Contrac'or <br /> Y To v^� to Rarga Sac o^ <br /> GIS Coordinates Y, <br /> WORK TO BE PFOFORMIQ <br /> N1,7�EW V�lELL!8OR1NG(CPT GEOrRC:BE HYDROPUNCH,hANC-AUGc� OTrIcR') CE,STO_C7 ON (ClIcose 1fc-a bet <br /> J't �,OVF=R-B4RE <br /> Q S^lL BORING * la PRESSURE-,RC <br /> 'Ctner <br /> CONINIFzNTS <br /> iYPE OF WELL IBIS i AL'_+TION TYPE CONSTRUC71C 4 5PCC1rrtC:71CNS <br /> NITORING '% -aOLL OW STE`.! DIA OF SOR=nCLS �' � MULTIPLE CASINGS'Q'SES �hC Iv'VEUL CASING DIA L <br /> 1 . a.1E=J <br /> C�lVEV CASING TYSC�1NE5S qCTYPC OF CASING Q STEL ;-­./C ©OTrER <br /> i P�C�QV <br /> (I VAPOR Q MUD ROTARY DE_Tl-1 of GROUT Scat 7_f�L,'•� i t�_,Ll[E i rPE TO aE us-0 {Q ALGE-S GF- <br /> 5 AIR SPARGE Q?USH POINT GROUT SEAL cUMPSO a Yes No (NOTE: MAXIMUM FRE=-FALL DEPTH IS <br /> a SOIL BORING (I HAND AUGER APPRox BORING CE-Trr_ Z5-- -U ASOLTELf TRAF=C BOX Of Q STOVE PIP <br /> (1 OTHER Q OTFicq CONDUCTOR CASING PROPOSED?___0_C(if YZS "t spec r=cnS hera) <br /> COMMENTS <br /> U:;; S l t <br /> NOTE_ OFrSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby certify that I have prepared Lits application and that the work wd[be done In accordance wdn San Joaqurn County Ora rances,State Laws, enc <br /> and hereby <br /> cet�f y t ai the San Joaquin County Honeawner ar licensed agent's signature=rbfles the following- "1 CPrtrtl that h7 ase performance of the <br /> for Rewtygulations <br /> this permit ht S ,«oaq 1 shat!not employ persons subject to WORK=RS'ComPENSA77ON Laws at Calrfarn,�" Cant<setor s htnng or c <br /> contracting argnatuts cemfaes the fotteNrMng- 't cerfrly that u?tha performance of the work for which Errs parmot is issued I Shalt Qrrpioy persons sub1ect" <br /> WORKERS COMPENSA 770N laws of Cafffrrrrta . <br /> CALL <br /> -TNEUNIT FVJNSPECTOR 48 WORKING HRS IN ADVANCS FOR-ALL REQUIREB INSPECTIONS. <br /> S <br /> C„"�y %, y Tdleicompam/_ <br /> igned X Crc'.?h3 <br /> Pnnt NameSCta l'i WI u 11 Dat_ Z <br /> lAiP --ja t #' � 411;7I K�P <br /> SI�E�`-5th - - _ -- <br /> DEPARTMFNT USE ONLY <br /> / . <br /> Data Issued Z b C� Area <br /> Apptrcatnon Accepted Sy_„�(11 ,tnnf2n^ Date <br /> Grout inspection By DaterFInal Inspecton By <br /> Destruction Inspection By Date <br /> commp-NTS f CON13MORS: <br /> 7ACCOUNNIMNG aKLY: ale+•ECs3ElE5 FEE IISFO AMOl1NT RF,!lIfTTEG CHECK 4 REC U BY DATE 7Et1rACf 1 S>ERi VICE�Ct]EST# iNVfllc5_0 i - �{$ .O fl Z I + Z O ZZ <br />