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WELL PERMIT WFLICATION FORM UNIT IV' <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION;(PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 9520FILE <br /> (209) 468-34.49 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE 1$34JED <br /> ApprGalirfi is hpre')y nosde to.`isn,;ucyum Csunty'rc a permit to ccnstruci artCror install the worst eascribed. This applIcnt:o:;r5 r,1►Yk u+cd,riuuni.e tir.:, <br /> anIZ-.jUin C:a:iniy nz.vaiopmr-int Tma,Chnpr�r a t i 1F.:1 inn t2r.SuinrEUr;c Of a.in.1-'%%wn Cour=ty lul%;H_alttt Services- <br /> `I As.csso+s <br /> WEL! Lacatlon_ f Cr_ss;tree! Crty..J�1. Z y��UQ f�r:.Fra <br /> ............ ..q.._._ _.. _. <br /> PROPERTY UWnB: _� - /1zGrC s..(��+7_�..lKjfA(,r . t-',yC_OI�L �tPJ���-Thcni: <br /> G•57[:cn1ra±c'.nr_&.� ��ft/�/(i7C!!...----.AJdrrxs, <br /> 399.c�l+itiS .P.,� .._ ..__....�'t:�Y�/ S�S� u3. z c'coIr .1"[,:=tea 77 is 20 <br /> Consultant/S[.b Contractor-6[ am Amrns /l 7/U &2!?!ru$ (.u}'�S�Grx/ (-:•;, � '�cnex.�,�p��- <br /> r�j. ._...._— RZrrF— <br /> r3 R <br /> (ArORK TO 9E PERFDRARED <br /> 19-4Sti'WEr ;�tfltilN! ki l4�ttqu�,F 01:+3P UN0, HI1.NC,.AiJf_ER GTHER.-} <br /> Cf L 80 !NG A _ / Z - }RE <br /> � <br /> TYF�OF WELL INSTALLATION TYPE COt4STRUCTICI+E SPEC IF-ICA 7IONS <br /> �.+40-417CRIN(; [f riGLL0411!'fL:ti', L);A u, ki'?h',�LLE- /�/-_mt,:i-lrL`1AZiNGSi(j `.'E� U NO :tic-L.C:r1:_:I!Q C,1!Z. ..- -- <br /> ]FXT-RAC7I;'1N I,T AIR. -W.5..MER:17DrZ VEN CASING THCKtiFSS NI't TIPS OF CASING DS I I-c(- Q <br /> aVFPrJF. QiV1t;Ci flGTA1iY f3E?_h OF UR4Ui SEAL_�� EFtEhtiF"1YP_ T 3E L'SFG ©AUt:cr:: Q;i <br /> QRI S?AFGF 'tLSH PCIN7 GIIC:tif SEAL.PUFF ft Q Iry ;(Nu (NOTE: MAXIMUM FREE-FALL DEPTH �S 301) <br /> SOIL BORING [ <br /> priRtiUAU�Eri F.!-'Ft:C?X r5:'HIMr3Utt=tt. __ �2CS�-.-'---=....QF3S}LTci]'RAF VC,R:'.x cT [;iTr":EPi=E <br /> 0 OTHER: Q OT <br /> COMMFNTS' <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS _-— <br /> i rarraoy curtiF}lha;!hada PrrarryrN�rh:s:aF_rl+ralirr.Ansi thaS t.�a w,:lc 1+::1 r.Q aono:n��cardance W•MI$an J_aq::rtl CJ:lrity Qra=13"=_=s i;La.e L.avox" aid R.r�eo <br /> art;;keguIat:on.of ho San.Kagam Gounve I-1z mc-owiw WS rkjrajfe tht:Fpkowng, "I certify 014f In fho perfor7ran Ce ur rhe work <br /> For which this perntir es Issues.!sna!/rro!eruploy ptprsort.s Subject IC WOPX�S'COMPENSATQN taws of California" C•��In�r.^[s^��rrc 9r;a;- <br /> ca^.vect.re eignntare GertiiseS the. fo!huir.g 'f rrr'a/>tisr ir.lee�!u'::rn,�:xr�f the.0.1 h r,rh;�.f,hrstrtrru:f i3 rss,rl! Jrar;rrrr:pl.:;pvrsrxa:;F�rj�r!r. <br /> 6�lJRr(c?$'COtifPrNcaTiOh'tsws of Cahla.nia" <br /> T ILNT ST L 8 1FYpftKING-AR5'IN.ADIIANCE FOR ALL REQUIRED INSPECTIONS. <br /> -- -------.......... . . .. .... .... T't� .+�.4.�'L--.—'� —•__,_C.tc I`/�r--�f - <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED: <br /> L4 <br /> DEPARTMENT USE ONLYlI 9 _ <br /> ' Applfca:'cn Ac:epted E?V_ ....,._.... . U�'r.Issc:rd aI -��r�/ <br /> Groh InapScticn Gy - rrtrL. Fir-at Ins;,ecticn By <br /> Daatrucricn inspoctron By hat. l <br /> COMMENTS I CONDITIONS:__--­,......... .......... ._.,..___.__ <br /> • 1� k <br /> 10 <br /> A,CCOLNTMG ONLY AId>s --- <br /> PE CQDE$ I FII:INFO AMOUNT, REM::TFD CHECK- RECD 8Y DATE F + PERtNl7 r SERVICE REQUESS p S INVOICE j <br /> T -I - !�Z/ <br /> C-57.--UCENSED C0-N RA(.. 0R-.MVST.I : 'UCENSE&WORKERS`:COMPOq5ATION DECLARATION <br /> UNIT IV•W23199!Sign bkpg/AAF <br /> s — .. .+ - - _ .. 4 :. _ _ ...rte •• .. ... s u y <br />