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WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.' <br /> ENVIRONMENTAL. HEALTH DIVISION (PHS-EHD) <br /> R. C . Weber, Third Floor, Stockton, CA.i 95202 <br /> RECEIVE (209) 458-3"9 <br /> ,n NON-R FUNDABLE PERorT EXPIRES I YEAR FROM OATS r <br /> Application is neredKed�I T� WIN County for a WMA to Conatrua andbr install the work desacnl}ed. This appveogg. is mane in I NHealt Cl wsi <br /> San.;osquir►County Development i1 ChL7H 9-t s.3 and the 5lannards or San loaeu ,u`ty P` Ik H��n Sanioss•Erwiro�r'►heath Qiuision. <br /> YbI kT+: `r?ap <br /> G�.ya�� Ptuvase acs '2 G'f �'r <br /> WELLCross Street O � I �-.-----..---... <br /> o A T?f r� Er" <br /> &1k rift Czo <br /> P 9 Y` 2 P707 <br /> PROPERTY Ownet 6 Address r v &�` !•L Ci A100/ <br /> C-57 / <br /> d lh" r C'. .v fA►--* dress 0 fie—-? Lir PhonaP, s-94-0*2-7 <br /> Consultant w <br /> GIS Coordinates:X Y!- P 4 O��Tamanio R:♦"9tr- 7� -Seam sSr <br /> t RI(To BE PERFORMED <br /> jrNFN WELL/BORING(CPT.OEOPQ OVVERBOREE ROSE.HYDROPUNCH,HANO-AUGER.OTHOM Q DESTRUCTION ERse typo Now) <br /> BORING 0 <br /> Q PRESSURE GROUT <br /> ,other! <br /> CommFNTS: <br /> TYPE OF I 4TA 1 N TYPE CON TRUCTSON SP CIFICATI � <br /> e'PkitONITORING �IOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?Q YES �QNO WELL CASING DIA: _ <br /> WO TYPE OF CASING: 0 STEEL Q OTHER: <br /> Q Ex-RACTION 0 AIR ItASAMERlORNEN CASING THtCKNES YE2Et4NE TYPE TO BE USED: Q AUGERS QHOSE <br /> I VAPOR Q mUD ROTARY GEPT14 OF GROUT SEAL � <br /> AIR SAARGE Q PUSH POINT GROUT SEAL PUMPSO' Q Yes Q No (NOM- MAXIMUM FREE-FALL DEPTH iS 30') <br /> Q <br /> a AIR <br /> Q PUSH AUGER APPROX.BORING DEPT14 11'BOLreo TRAFFIC BOX or Q STOVE PIPE <br /> V'SOILQ 0_�ER:��_A OTHERCONDUCTOR CASING PROPOSED? {ii YES.lift ap*aMaliana ElArsl: <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> i hereoy certify that I have atepared thin spplicauon and Ihat the work Will be dons in accoreance until San Joaquin Caunry Ordinsnrxs,State Laws.arra!Rules <br /> and Regulations of the San,rosquin County. Homm weer or licensed agenl'a Sig <br /> rtsturs certifies the following:"f tadwy that!w the pertbnnsnca of the wgrk <br /> for which this 0ormir is issued.!shall"Of employ paraans subject to W0R9ERS'C0A#PemSA7loN Laws of CawM2 mr." Coammes nifinq or wo- <br /> contracling signature certifies the lollowrng:'f c@aNy khat in wfu porramance of tits»ark for wakh dtia pasha is i 4uod./shag emAwoy pa VwC Saejacr to <br /> WORKERS'COMPENSATION taws of CJ0h"w-- <br /> THE LICANT MUST CALL" HAS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Title <br /> signed <br /> E MAP IN UNIT IV WORK 0"ATED <br /> 94 <br /> �[ DEPARTMENT USE ONLY <br /> Aoolio3tlor Accepted By ` �-� � _Ogre Issu '—/ - -area /)7 <br /> ep <br /> Grout inspaceon Ay Date Foal Inaeamon By Oat* <br /> Oealruction Inaoschon-ey Data <br /> COINMENT3!CONGITIONB: <br /> FAC*ACCOUNTING ONLY: AIDS <br /> Pe CODES FEE INFO AMOUNT REMITTED HEG ASN REClftvQD BY DATE I PERMITwSERVICE REQUEST NUMBER INVOICE <br /> C-57IICENSEn CQ GT RmusT SIGN IICFNSE&-T0kM 'C©b2=4SA-T1PN DECLA LATION <br /> UNrT P/-6/23/99/sign bkpg/MI <br /> Z0 39VJ x 00000000000 65:ET 6661/9T/1-0 <br />