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WELL PERMIT APPLICATION FORM . UNIT IV <br />F-- V E D <br />SAN JOAQUIN COUNTY PUBLIC HEALTH -SERVICES3 I <br />ENVIRONMENTAL HEALTH DIVI51ON (PHS -EHL)) FEB- 2 2 2000 <br />304 E. Weber, Third Floor, Stockton, CA., 55242 <br />(209) 468-3449 ENVIRU�,!iYlti� iHt• H' =ACTH <br />NON=ft FLE INOAE3LE PEKDnIr tXPIRES 1 YEAR PROtit DATE I;i5UEl7 <br />PERMIT/ Strf-tvt�,�� <br />Aication it hereby maria to San Jvartuin G7unty for a Permit 1. c 1 ,tn,ct andror install the work drsulbed, itu: application is m Ida in cot rplianc^ with <br />) Jpaquin County M,) el tO Sall Tn1e, chapter 9.1 t 15.3 and the c tnndardu of San Joaquin County Public; Health 5ervtccs. Envlronmental He, lth Division <br />r Assessors <br />:LL Location <br />< ross 5lr:Cl Uclk <br />—��rl�i� Address :IC��l1��s�i�ctl city. <br />OpERTY Owner r ��''TT <br />I <br />57 Gontractor_FAddress <br />/rjKl�lnr �f_r�-ll.t f <br />13(, S <br />(� Addrt ss V City 1�ikC{�i./l�lc# Phonem_L*l . <br />ursultdnt /Sub Contnctor�.�-i���. — <br />. Y , Trnvnship r ur'f"f'1- _ Ronge f�? t-t4t Section_.. .7_� <br />7R__ F�p pE PEKFURh1ED <br />f I tyDf:OPUNGH• HA�;0-AUGEI .OTHER•) U DESTRUCTION (choose tyR: a'fow) <br />NFW WELL) 8r1RING ( CPTH -FOPRo U r [j QNrER-FSI�RE <br />j JIL BORING: u �� — f—�tr� '•}J ! ❑ PRE33URE C:RUUI <br />U WELL k_ <br />)cher' <br />UMNIENTS: <br />CE OF WELL INSTAI,LATION-T_YPE SPECIFICATICINS <br />HVLLOw SiEDA DIA. OF GGRFHOLft MUI TIPLE Ch,INGS? B YES 0 NO WrLI_ CPiICJG Ulh. <br />PAaNITOF.ING OTHER'. <br />v Q AIR HAPQMFPJDRIVEN C.AtiING THICKNESS TYPF OF CASING' 0 5 F EEL Q PVC Q <br />EXTRACTION <br />TRFMIE TYPE 7013F- U5E0: Q AUGER SHV.• <br />im <br />VAPOR � titUD RrJ YAR'Y DEPTI I OF GROUT SEAL_ . <br />AIRS PARCL p PUSH 17`011`41 GROUT SEAL FUMf'Ep. ji'fes ❑ No {NOTF: MAXIMUM FREE -FALL DEPTH IS 30'} <br />{ r � a HAND AtJGFR Ar PRr)X. BORING DEPTHrja�A IJ � (1 SO[ TEU TRAFFIC BOX or Q $TOVt PIPE <br />OIt_ BORIN <br />OTHt: Q <br />OTHtiR— CODIDUGit)Fi CAiING PROPOSED? (if •f ES, list s�:.iriGatio+�n koro):.„__ <br />:OMMENTS: _ _ <br />NOTE: OFFSITE BORINGS RI�(�lilRE ACCESS OR ENCROACHMENT PERMITS <br />and Rules <br />hereby ce tity that I have prepared this af'Phc atiun and that the work will be done In accordance with San Joaquin County Ord mncesne p-1 formance of rhe work <br />rnd Regulations of the San-ImAquin County. Ho o�Vnti t tanW7RK c ContPPNSATION taws of G lif rniatifins the 1`0110-111T ccriff <br />I jt f 'ncontranor's hiring or sub <br />rot Whr'eh t✓yFs permit !s issurcl, 1 shat! not employ Aersvns uf <br />:onrracting s gnahrre certhes the tni!crNing: "f rsrirfy that rr7 the partormance of tho work fur whish this Permit r:: rssued, t .Chart employ Pe��'?subjectCO <br />NORKERS' C0MPEN3ATICN Laws Of Cahr4rrrra." <br />CALL THE UNIT IV INSPECTOR 4I3 WORKING FIRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />Signed x✓_' `{ L' Vs �L��� Y`� _TitlJCvrnpany_W — <br />.i r1t}16ryl ----- — <br />Print Name �,• �� <br />SEkSITE : MAP IN :UNI;T' JV WORK PLAN DATED;'- <br />D[PARIMENT USE ONLY <br />Application Axepted Ely— <br />Grout Inspection By��f2� <br />_Datei��3/ o a—Final In:;pectx�n 15y -- <br />Date <br />Destructios <br />n Inpection By <br />COMMENTS I CONDITIONS- _ <br />ACCoUNTINc� OtJtY: AID# }1CtI <br />11F_ST R INVOICE <br />PE CODES FEE INFO AMOUNT REMITTED CHECK 11 RECD BY DATE PERMIT 15ERVI(:E REQ <br />3 <br />�8.'_bi3bi36U.' t.)uI `�HI'1 eJ 1 t01 00 le.; qjj <br />