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10-13-1998 ltd 42AM FROM Y � <br /> WELL PERMIT APPLICATION FORM <br /> UNIT IV <br /> SAN JOAQUIN COUNTY PUI3LIC HEALTH SXRVICES <br /> ENVIRONMENTAL HEALTH DIVISION ("PHS-EHD") <br /> 304 E Weber, Third Floor, Stockton, CA., 95242 <br /> (209) 468-3450 <br /> NON-REFU 40ABLE PER AIT EXPIRES 1 YEAR FROM GATE ISSUED <br /> This applIcstton is made in compliance vAth <br /> kpplicabnn ts hereby made t Tide Chapter 9-I 115 3 andt the S to andants Of San Joaqwn County PuW'or Install the wock c Health Sp-rvLcas Environmental HeaiU+Op son <br /> tan.Ioaquin County DevelopmentAssaSSaf's <br /> IvELL Loc3dan $ i Croomss Street,. ,_k rnan _Cdy t! Ip—�- <br /> ParceNf Oqg-OSO'3� <br /> Sv%f C aosr,o��si.�rr plarR zip ��pnonel! <br /> PROPERTY Owner <br /> ddress 9 S C1ty o <br /> 9 C,h'���-1>ezZtp9Y'SS�L�y�s/G5 Phones+ 9zS•_3I3�� <br /> C-57 Convector G►�� ►'- ✓ ddress t7 � a <br /> "fZn !?.�lr n7{ Sr —Gty a c�L,C0 PhonB <br /> Consultant J Sub Contractor +n ddress�,y,.,.� <br /> GIS Coordinates X Y Township Range <br /> Section <br /> WORK 70 aE PFFZFORMED <br /> �O1rSTRUCTiON (chaos type oetoV+) <br />(I NEW WELL/BORING(CPT GEOPROBE HYOROPUNCH HAND-AUGER. OTHER") Q OVER-SORE <br /> firSOIL BORING 9 f 0 PRESSURE GRoLrr <br /> WELL# <br />_O <br /> C NTS <br /> I"Y F WELL CONSTRUCTION 1-fPE CONSTRUCTION SPECIFICA=NS ')OYES <br /> Y WELL CASING DIA 1 <br /> MONITORING HOLLOW STEM DIA_0>= BOREHOLE�MULTIPLE CASINGS Q E5 E'NO -` <br /> tie TYPE OF CASING Q 57EEL PVC OTHER <br /> EXTRACTION Q AIR HAMMERrDRIVEN CASING THICKNESS HOSE <br /> VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL,~ �fO f��� <br /> ' TREMIE TYPE TO SE USED AUGERS (I <br /> DEPTH tS <br /> Q AIR SPARGE Q PUSH POINT GROUT SEAL PUMPED �Y NOTA. MAXIMUM Ot T£D TFtAFF C SOX or La STOVE PIPE <br /> oi, <br /> aSOIL BORING [ NANO AUGER APPROX-BORING OEpTHar_ <br /> a OTHER <br /> CONDUCTOR CASING PROPOSED?—(if YES list specs6cavons here) <br /> COMMENTS <br /> NOTE. OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS! <br /> I Hereby canify that I have prepared this application NaMe n@r or Licensed spent sat we warik-ill be os signature rome in tes thace ttori s w�ngan aol certify n r a dime firma ea of the work <br /> ani Regulations of the San Joaquin County <br /> for which this pets <br /> rmis,sued I shall nor Bn7ploy persons sub)ect to WORKMAN'S COMPENSATION lbws ofCsljfomJ-v Contractors hlnng or 5u <br /> contracting signature certifies the following "I cerr�fy that Ln the peffon174knee of the work hrrwhich(his permit is rssued I shall employ persons subject to <br /> WORKMAnrS COMPENSATION Caws of Cafilorm'Zi <br /> THE APPLICANT MUST CALL 48 HRS IN ADVANCE','FOR ALL REQUIRED INSPECTIONS <br /> Title ate / l- : <br /> Signed x <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED <br /> EPARTMENT USE ONLY / `� <br /> • Date issued 3/ ZW Are, <br /> Appitcstson Accepted By 03ie � <br /> Grout Inspection By Date Fina+Ir40eC1JGn By <br /> 9dwcoon Inspection By Oats <br /> .. ENTS I GDNDITIONS <br /> FACx <br /> FACCiOUIN;1TING ONLY 1 <br /> 1O>x <br /> FEE INFO AMOUNT REMITTED Cl tECKJ-UCASH REC D DATE PERMITISERVICE.REQUEST NUMBER INVOICE <br /> 1 _ FLO Q 1 12- Z 3 " <br />