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f <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION ("PHS-EHJ") <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3450 <br /> NON-REFUNDASLZ PERMIT EXPIRES 1 YEAR FROM DATE 155U%2 <br /> Apolicat;on ie horoby m.2do to San Joacuet County for a permit to consbtrd andlor insaa0 the worst des wibed. This appli aWn is mace in cmToftnee wiM <br /> San Joaquin County De"k rnent This,Ctaaptw 9-1115.3 and the Standards of Says Joaquin County PWtc Health Services, Env*onnwtal f ieatth Division. <br /> 37 West Sonora Street S. Center St Stockton 95212 - Aocwsuors 137-31-16 <br /> ' WELL Locstioet _. Crtass Street. City Tp PaMMw <br /> PROPERTY Ovrr TBPOE of .W. Lodge Id14 ddrotac P.O.Box 691985 C,jty Stockton Z10 9521 <br /> C-57G4rttraCsor Vironex, Inc. Addrm 23726 Foley St.#7 rry Hayward 94321i,*705927phom,#510266-0966 <br /> Cansutt M/Sub CarrtraCtor Twining Laboratorie�dr�2527 Fresno St. C4 Fresno Li[. pMneg559-268-7021 <br /> iGIS Coordinates:X„7¢ �7�3�� Y �a 7.�B�Tow s* Range Section <br /> WORK tp DE PERFORMED <br /> NEW WELL.l BORINr.(CPT.. Of!Rios tiYDROPUNCH. MAND,-�UGt`.R.OTHLIR-) II 0ESTRtnn0N (ct+ooea type below`} <br /> SOIL BORZ}4l A' OVER-BORE <br /> WELL# J�`�7, jj PRESSURE GROV7 <br /> COMMENTS-, <br /> ' ;YPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br /> I]MONITORING D HOLLOW STEM OLA.OF BOREHr—N E U rtO WELL CA3Ir%3 DIA <br /> f]EXTRACTION a AIR HAMMERfO LIVEN CASING THtCKNF-," TYPE OF UASIN43: a STEEL p Pvc p OTHER <br /> VAPOR Q MUD ROTARY DEPTH OF GROLM SEA.LL TREMS TYPE TO BE USED- Q AUGER$ 9HOSE <br /> D AIR SPARGIF JyvtJSH POINT GROUT SEAL lsLWEa. a Yes No (NOTE: MA)OMUM FREE-FALL DEM IS 30') <br /> 0 SOIL BORING D HAN D AUGER APPROX.BORING OEPTH 5 ft o SOLTED TRAFFIC BOX or ©STUPE PfPE <br /> a OTIHM, CONDUCTOR CASING PROPOSEW No (It YES.fist spec3t'rcabons here): <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS? <br /> hereby Certify that i nave,prepared this applieat and that the wort will be don*rn 2=.0rd2nCe with Sats Joagvin County Ordinances,State Laws,and Rune: <br /> and Regulatiums of the San Joaquin County. Horneawnst or fioensed agent's s9aature certifies the Ioliowin¢ "l eerrlfy that in tie performance of the work <br /> for"Ich Mrs permtr is lssued,t shall r+ot employ persons subject to Wt7RKMAH'5 COMPENSA77ON Lsww of California.- Controatofa hiring or sub- <br /> contraCtinq Sionatttre certifies the foDwAng:'f Cartify that in do perkmu noe of arae w"for which this patttW is issued. 1 snda arnpfoy ptrr ons subject to <br /> WORKMAN'S COWENSAnON Laws of C.agbmia_ <br /> THE APPLICANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> 'Signed R � (u rrtte L�f14� Z.r yr ST:✓mate I2/e�9f <br /> SEE SITE MAP IN UNIT IV WORK PLAN. DATED 12/6/99 <br /> ���ftTMefeT vse ONLY I►axptrd BY - --— Bate!maned Area <br /> Grout insoeetton By Date Final Irt90ection By Date <br /> Oestruction Insvecbn By Date <br /> COMMENTS 1 CONDI'I'IONtS: <br /> ACCOUNTINO ONLY: AIDO FAC# <br /> PE CODES FEE INFO AMOUNT REf !T'I ED CHECK#ICA5H RECEIVED BY DATE PERMIT15ERVICIE REQUF-ST NUMBER INIVOIC <br /> UNrT IV-5/99/AU <br />