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!I -=a -r <br /> WEL'ePERMIT APPLICATION F07kM 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-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> Apprc,iiar is hereby made to S;u,vuayurn Caunry fOr a permit to ccnstruct anCror install the worK described. This application s m.l•Yr. r„CO,r,plruni.e won <br /> fan.laa�uin County D-✓alopmenr Tin?,Chnntp`r a 1 1 If-.S anfl t^a Of 5:tn,IOdOtl,rt COWI!y PUhlic ttc181th Swvrces.Envrroa^,enta:t-ea!:h '1`,s;u:' <br /> WELL Lccatlon�� JYfJt ST Cr s:Slee! /h/#/,1/ Crl �� ./ �q Assessor, <br /> Y.C..Ia/S4N-....._j'?..1� �.._fcr:,Fra <br /> n - <br /> PRUPERTY Uwne: —._.._---!laer__:5 Zli(��/-. 5.,......... `Y i'hcncz <br /> xQ .�2 jay .. .... �'. _ /t:r.c��f� <br /> C-57 Cmtrac!w .sl/ '/l�l�L .._.._.._...AJdrea.s!//..5 /�s.//. .._...__.......C ���A—I+...s'_rp sal CA(t � _}'•, :ua,72�:.3510 <br /> Consultant/SLb Conlrac:or —Acarc;s J7/1/Jhh/AI <br /> GIS ccvj rat". <br /> __ff C_._..-- <br /> W RK T_BE PERF;,RM_L'D <br /> .Z<"ti'WELL' -)KING CP1 GtitHur>eE.ttYOROPUNcCH.HAND-At�.'3OTHER <br /> .1i <br /> GTHE •i <br /> BORING 1��j. CF T:+'N;'!{;N 1`r;rt•ise:y;c vriaw <br /> Q Y - <br /> p..,VF.R-BORE <br /> lJEI.t. <br /> _......�..... .....-,.,.....-- --- J--RE2SU!tL motive:- <br /> Otlzcr. .__.—._. <br /> COMMEN-S' --------- <br /> TYPE OF WELL INSTALLATION TYPE_ COhSTRJCTICN SPECU-ICATIONS <br /> 0 MOVITCRING ©HOLLCAN L rE1: UTA 08'LR_HCX6_._. ._--PAL:1.7 LE v`- GVG '%Ee. <br /> Cnc;1hG L a <br /> 1`r]EXTRAC110N C AIR.NAr0.%1=_Ri0R-VEN CAS:Nr'>THICKNESS _ TYPE OF CASING 0S I Icre. C•"�i; C t?iH � - <br /> o VAPOP, Q MLD ROTARY DE--H OF GROUT SEAL-�— IK_R!1E'TYP= I 3E USLn <br /> 0 AIR 5?ARl3FUSH POINT (,IZ:;IIT$iii PUrnF't es �NJ NOTE: MAXIMUM FREE-FALL D=PTH iS 3G') <br /> JK_Oit.BORING 0 HAND AU�ERt P.�'h'I:V x. LS JN1Nr�Utf t1 � <br /> ------__--.0 BOeTc.D?FAFp'C f,:'.X I:1` C iT!:":E PI=E <br /> Q OTHER: 0 OTHER _-_.....__._. C:ONDUC 1`012 CASING 212?PCScD�_ ---t if YES fst spec`iwCr;1`'4 here: <br /> — ----_.....-..----- --------- - acct <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I tt:rnny Grind}that I haia prat,arad this Vphnxitgr.aril that via wz-k X;.I re rSOne:n aCGY'anC@ w tri San Jcaqurn County Qratn:-,==s SI+ve e.:+ws, <br /> arz 4E-gJl:tion:Cf too San JCGagarn ;r Hdn.Cowi,:rr of 6car.ssnC a9e, s swratre zertifies th_fohowrng. '!certify that 1n tho peifortt• ance u1`:he work <br /> for wh!ch this permit i5 isSUHaj,/Shall n0f employ'versorts subject le WOP.<ER.S'COMPEVSATTON Lawn o!California ;.��Ira�t^r s^r.rrg Or;•:L'- �j y� <br /> corcrtet.ne ei_neture certifies!hr fo!Ip-ving 't err:!/M1,9r r• <br /> 1`r fhn rr!::1`r..-)nrr o(,,hC work N r,rh;�:h,this)rcrrr,;f 1`s iycocJ.!slr_�U 1rrph:i f'rrsnns su:.iY;7 <br /> kvORK RE ."�PEAI •N Lawsof Cehfuu,iaNT MtlST. At!`�v V Y RKING NR5 IN ADVANCE FOR ALL REQUIREO.INSPECTIONS. <br /> Siynod z r <br /> __ _.._..... . tk �k t.£,f. Cite_ <br /> SEE SITE MAAP N UNIT IV WORK PLAN DATED: Nfsy,.6r <br /> • DEPARTMENT USE ONLY <br /> Applicatc•n Ac;rpted BY lte. Cqn>^ _...__._.._._----......._ .. . Ue!r.Issue.. <br /> l !!! Act <br /> Groat Ina ecticn 6 l z Sf - <br /> P Y - — h........._.._...,D'r�..._._ Fir.al Imgtc!icn BY <br /> Doctrucuon Inspochon$v hOt. <br /> ...................... <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY AID# <br /> ------._. .-.------------ FAL i; <br /> PE CODES I FEE INFO AMOUNT REM:TTED CHECK Ir I RECD BY DATE r PERMIT r SERVICE REQUEST a t INVOICE S <br /> --- _ _ <br /> — ..._.� . <br /> iso( <br /> C-57':LICE.NSED CO»'TRACTOR:MUST SIGNINCENSE&W'ORKERS'.Ct7MPx�'SA1f'ION DECLARATION ZV.6/23/99/sign bkpg1Ml <br />