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WELL PERMIT APPLICATION FORM UNIT IV <br /> w <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) -7 <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (249) 468-3449 <br /> NON RE71-!NDASLE PERt,11T EYPIPES t SEAR FROM DATE 1SSUEQ <br /> rppl1C3t1On 15 ITEr8tj^sada i0 San .Ica.:_n Co,zn'/for a y?=rC to C�n�"..0 3^r�C'yrs a I the ocr<disc,:^ d T`,is aopi.caa'on T is'—pace to =r-plianca mt' <br /> pan Joagjtn County Oerelop"nent!E1 i it'e C`aP of 9- 5 3 and the S:a-iea-os cr Sar -cagjsr C3�r Pu -rc ieai"s Sa^jlczs E c^rze^-si -eal`^ D r s c^ <br /> r LocatiLocation �!�! ICX � '� c C,oss S,ree: cV`l 4 Clty S Z p Parse T <br /> ry: <br />'jRQPERTY Owner C-, <br /> Address <br /> -Z3Z zw 7 <br /> r �� C.y �� ��„�u��so q rCu� L cam' CL cher <br /> -57 Cantrsc•ar (Tt 1 - 1{.K, Address CC. t .,t S <br /> 3orult�nt I Sub Cantcac�a. t c •`` }✓ ~`L Address ' dam+ G ty1 n t' �cne:SJa 'i-"fl -JJLC <br /> 31S Coordinates X <br /> Y Tcwrss'^io R3rge Sac o•s <br /> NORK TO BE PERFORMED <br /> OSSTR.,c tON (C^case tyc-3 male ti <br /> 4,yi;+NV11ELLl BORING(CPT Csct:r°CBE H"Dr-tCPi,NCH HA[�tC-AUGcR, CiTr=R'} Q � OVER-80RE <br /> j SOIL 3CRING PRESSURE GPGU- <br /> 'Other <br /> COMMENTS <br /> TYPE OF WELL INSTALI-.AT;ON TYPE CONST RUCTIC 4 SPECIE C-%TIONS <br /> ITORING [Z HOLLOW ST=-%l DIA OF SCR_-iCL;—Z ' %AUI TIPLE CASINGS- Q`SES E NO, aVEU CASING DIA <br /> O�? "1=:PI0RIVEN CASING TFICe,yESS TYPE OF CASING Q STEat Ell -VC Q OTHER <br /> (] <br /> VAPOR h1UD ROTARY OE=TH OF GROUT SEAL_ TREy11E TYPE TO BE LsSEO S AUGERS OHC <br /> Q A15Z SPARGE PUSH PCINT GROUT SEAL oUMPEO 11 Yes ,�f No {NOTE. MAXIMUM rREc-FALL DEPTH 15 3 <br /> HAND AUG=R APSORING DE=—t,- -3 ]�SOLTEO TRAF=iC BOX or ti S T OV=PIPE <br /> ,4501L BORING <br /> [�OTHER []OYME� CCNDUCTbR GaSING PRCPOSEI3?,- (if YES,Inst sPeC:'"' :.zs vera) <br /> C1 4n GI. 5GI MA S <br /> COMMENTSTP HIJ7C)/"C.�:v j... ,`r1,1•, TO Cj .t so, <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> s hereby certrfy that I have prepared tftrs application and that the worts will be done n ac=rdance wr`,tr San Joaquin County Orb=s",State Laws -arid R <br /> and Regulations of the San Joaquin County Horr•eowner or Itcensed agents signature=rhfiea the following "!Cerlrfy that in bhe perr'ormancc of the w <br /> sub <br /> for which the permit is#=ucd.I shadi not amPloy persons suDfect fo WQFZICe`.-cS'GCJ+NPE?iSAi 12.Q 71t IS oI Cal F Sh ICY P c:or s h mbJ ar o <br /> Ccntractsng»gnatUM CCMfiea the foltawing-'1 Certify that rn the perfarmarres of Urs work for which this permit fs usueC l SI7aA errrploy persons suL�sc:to <br /> WORKERS COMPENSA77ON Laws of CaRbmia - <br /> CALLTHEUNI�SP 48 WORKING HRS ll�f ADpVRi�1.L�FOR-{L�>�flU�RF.O INSPECTIO�� � <br /> Signed x �� Ti icornparry f SCI 1 �'^'L,j7"r C�- <br /> Print Name C _"- <br /> �3A► lw <br /> SE�`_Sir�-MAP-tN-'Ein1#'F�1� <br /> DEPARTMENT USE ONLY <br /> Date Issued 'Z- OP Area <br /> Applwauon Accepted <br /> Grout Inspecnott By <br /> Date Frtai tnsfse�n Data <br /> Destruahon inspection By Date <br /> COMMENTS I CONDMONS: <br /> ACCOUNTING-ClVLY; +AIOO <br /> PE CODES FEE INFOAMOUNT REMITTED CHF-CK X RFC'D t3Y DATE PERMtTI SER VICE R<7UFSY� INYOIC <br /> 3�v 1 - �s`t. a° a°lZt ( 3 as O R 10 ZD <br />