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0 0 <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION ("PHS-EHD") <br /> 3014 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3450 <br /> NON-RFFllNDAB E PERMIT EXPIRES 1 YEAR FROM DATE IS51J15D <br /> Apoki=tion is horoby m2do to San Jozouin County for m Derrni to construd and/or install the work described- This app6cetion jS made in cornpfsrrae with <br /> San Joaquin County,Dew kn nent Tale,Chapter 5-1115.3 and the Standards of San Jwuh Courtly Pubric Health Services, Environmental Heafth Div� <br /> 37 West Sonora Street S. Center St Stockton 95212 " Acawtzers 137-31-16 <br /> WELL Location Cross Street City To Parceiii <br /> IBPOE of W. Locke Ial(Addroso P.O.Box 691985 City Stockton no 95214nme# <br /> C-57COntractor Vironex, Inc. 23726 Foley St.=7 rhy Haywazdgp 9432 705927pt,o,,ey510-266-d9b6 <br /> Gensuttant/Sub Contractor mining LaboratorieA�ddrM 252.7 Fresno St. Cjty Fresno Lim Pram 559-268-7021 <br /> GIS Coordinates:X 4t 37 - 50 Y Loj�ja} 1T.4."'Towem p Range Section <br /> WORK TO 8E PERFORMED <br /> Yo NEW WF_LL 1 BORING(C-PT.InligPROB KYOROPUNCH, 'HAND-+uJG!R.OTHER-) n pEs=FrucilON (cx*aoae type beiaw; <br /> 0 SOIL BOf Cyt 0 CM R43ORE <br /> }j WELL# 33�v o, j] PRESSLAI E GROUT <br /> "Otrtpr, <br /> COMMENTS: <br /> YPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING p HOLLOW STEM EXk OF BOREHOt= 1 112.-'PA1LTIPLc GAS04t3S?J�rES 0 r►o wFLL GAStNa DIA <br /> EXTRACTION Q AIR KA.MMERf0RFv=N GAZING THICKNF-yy TYPE Or CASING: a STEEL a PVC ❑OTK <br /> >0 VAPOR �MUD ROTARY DEPTH OF G;ZCKJ T SEALL TREmIQ-TYPE TO BE USB: Q AUGERS (3)4CSE <br /> p ATR SPARGE D:PUSH POINT GROUT SEAL PUMPEt7 a Yes i No (NOTE. MAXIMUM FREE-FALL DEPTH IS 30') <br /> p SOIL BORJNG 'a mAND AUGER APPROX. BORING DEPTH 5 ft 0 SOLTED TRAF-C BOX or a STC7VE PIPE <br /> a OTHER CONDUCTOR CASING PROPOSED? No (if YES.fret spec6kabons head): <br /> COMMENT$: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS! <br /> rwraby c„rtify that s hsve pre"red this application and that the wom wi6 be done in aac =nce wiM Sirs Joaquin County OrdirmnceS,State Lama,and Rune, <br /> and Regulations of the San Joaquin County. Flonrwmwner or Ftt:ensed agent's sigsatu a cwtifvs the fogow4u! "1 eefdfy that in the perfo"ance of tht worfr <br /> for wf71C17 ails pefmIT Is Issued,13nan not emplay persons subjcV to IAVAKMAArS COMPENSA77ON Lawn of Callf6mia.` ContraotoYc hiring Or Wb- <br /> contracting Signature Certifies the foRowirtg ."Camfy Uw in the pedbmanw Of tr*work far whkp dk3 pe mi t r3 issued. 1 smal aer7pky person 4 sldD w to <br /> AOORKMAffS COAfPENSA7(:W Laws Of Cal7fom4L' <br /> THE APPLICANT MUST CALL 48 HRS IN ADVANCE=FOR ALL REQUIRED INSPECTIONS. <br /> Signed x `LGL o ---- <br /> SEE SITE MAP IN UNIT IV WORK PLAN. DATED 12/6/99 <br /> DePARTMENT USE ONLY <br /> Apr 4oction A4cepted @y Date Issraed Area <br /> Grout 1n=*Ctxx BY Date Fi wt Insoection By Cate <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONDITIONS: <br /> f=AC# <br /> ACC.00JM'tNi7 ONLY: AIUt! <br /> PE CODES FEE INFO AMOUNT REMTI I CHECKNICASH REMVED BY DATE PERMIT/5ERVICE RLp'UF-5T NUMBER ll INV01C <br /> s l <br /> UNIT i1/-5199/AU <br />