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r� r <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> . SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA , 95202 <br /> (209) 468-3449 <br /> NON REPUUDABLE PERMIT EYPIPES I v=-AR cROM DATE ISSUED <br />\ppllcnt[on is hereby-rade to San Joao;.n Cosn'v fo a pe^^t Lo cvnc,-L1c';rr-jv 7s ail the vor[C,scnead Tbis aopi citron is -ace �n cc-�p��arGa x�t` <br /> pan Joagsln County Development T,le C aP'ec 9- 1 5 3 and the S=ncarMs er Sa- .--aq jlr Ccs-^y Pun is Heal;`i Se^LiIrz3 En -east', Oivis or <br /> Assesso <br /> NEL L Location �ti ` �t � f`'4 at yrs' Coss Strew' J City ; Z p Pa.cal' <br /> � In -C I�t� a ry�4ru <br /> 2AOPERTY O ti. kl� Acd'ess Z p <br /> Owner �- <br /> [.� l D I I €� C, z 3 �� <br /> 3-ST Gontrac'or �'� t r �� Address_ ! c�` � I C ty P <br /> 3an�.Sulta t/Sib Contrac'G" C.rt--r� �%[`"� Rddross <br /> aIS Cnordrnates X <br /> Y Tcw7s"to Rarge Section <br /> WORK TO BE PERFORMED <br /> NEW WELL 1 BORING(CPT GEOoROBE HYDRCPUNCH, H4ANC-AUGcP O '4=-=t'} Q OES T r2GGTION (goose.yoe belov, <br /> 5 SOIL 3CR1aVG i3 OVER-BORE <br /> Q <br /> 0 OIL , 0 PRESSURE GROU <br /> '4th e r <br /> COMMENTS <br /> TYPE OF WELL INSTALLATIOI`I T lPc CONST FZUC i 1CN SPECi;IC-;TIO4.S <br /> lTpftltSGHOLLOW 5Tcti1 pl? OF 3GRE-TOLE MULTIPLE CASINGS7 (]YES B NO WELL CASING DIA z <br /> • =� �� - e `IC Tx'iC 'NS''SS ��%4'1 ••C- OF CASING Q STEL SVG Q OTHER <br /> L'1 4 I R;C�iCN ll -\,F --' _ - <br /> Q VAPOR p MUD ROTARYJ DE=TH OF GROUT SEAL_- Zr'�-T T-riEMIE TYPE TO BE US=O Q AUGERS Q)"[Ot <br /> q AIR SPARGE Q PUSH+POINT GROUT SEAL FUMP_O a Yes 13 No (NOTE. MAXIMUM FREE-FALL DEPTH IS 3( <br /> SOIL 30RING Q HANE)AUG EP APPROX SORING DE H= 2-57' kLBOLTED TRAFFIC BOX or Q STOVE PIPE <br /> Q OTHER Q OTHER_ CONDUCTOR CASING PROPOSED? n v3 ( if YES list specificatro-s-cera} <br /> . I <br /> COMMENTS �� S I �.n �,�2� S f ,� •;/� <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby certify that I have prepared L`us application and that ttie work will be done in accordance with San Joaquin County OrCtnances, State Laws,and R <br /> and Regulations of the San Joaquin County Hor-aow-er ar IUce^sed agents signature certifies the following "f Certify/that in the Performance of the w[ <br /> for which this permit rs issued,f shaft not employ persons subject to WORKERS C0MPENSA770N Laws of California_" Contractors hiring or sub <br /> contracting signature certifies the Folle mng '!certify that in the performance of th9 work for which this permit is issued I Shall employ persons sublcc-'to <br /> WORKERS COMPENSA77ON Laws of Califamla <br /> CALL THE UNIT INSPECTOR 48 WORKING HRS IN ADVANCE FOR-ALL IREQUIRED <br /> INSPECTIONS. <br /> Signed x <br /> 7�, TrttelCampany c. Sir e nT-,s ~ C&I <br /> Print Nartit ' a� s ]RKPN-DATEE3w`"Y� <br /> SEES SFTI�-MAP "IN--UFg1'�` __ .�,—D <br /> DEPARTMENT USE ONLY <br /> �r� data lsstted y O Areae <br /> Application Accepted By b ,.w nIYw i- <br /> Date <br /> Grout Inspection By <br /> aate Final InspeGion By <br /> Destruction inspection By Date <br /> COMMENTS 1 CON17fTtONS <br /> ACCOtlP1TiNG ONLY Al0# <br /> PEC FF INFO AMOUNT REMITTED CHECK 9 RECD BY DATE 4t9ERMkT2ERViGCREQi1E.ST# iNVOtCES C7 0C7 dt , <br />