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> a <br /> o ', <br /> CN <br /> WELL PERMIT APPLICATION FORM UNIT Iv <br /> E � SAN JOAQUIN CGUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHY-EHC) <br /> ;.- 304 E. Weber, Third 7-3aor, Stockton, CA., 95202 <br /> W (209) 468-3449 <br /> NON-REFUNDABLE PER, <br /> ,AlT F-XFiRE5 t YEAR FROM DATE 133UED <br /> Appncalicn it hereby made:o sxi_�agtwi C: +Jrty tot a remit to ronin 4;-.zndkv mstalt:n'^lvor-�descriced �hfs aoplicztion s rna-�a or.ror phznc-wir <br /> ? Sar,JoaquT,County')evelopmen; .Me.Chap'er 13-1.115.3 and the Stan4arYs of Sar•Joaquin Eo,nty?,:b5c Heatth seri xs. Erx ronreotat Health Division <br /> W 11th Street Chrisman R Trac 95376 Assesso s NSA <br /> WE_L Locition C.-:ss Street ily_ y Z!o Parcesif <br /> I PROPcRTY OvmerSan JoaClUin County Address City Zi7 PhCne4 <br /> Spectrum Exploration <br /> CST Ccntr.cto- Address_ 236.5 Wigwam­-- c+t�tock -a_��2A`��122fr -4fi59712 <br /> The San Joaquin Company 8617 Etcheverry _ Tracy L!ca pl,o^e�209) 832-2910 <br /> Consultant,Sub Contr2etor -.ddmss qty <br /> GIS Csord.nat=s:7i .Y Tawnsnio Range SE[Fior <br /> j WOR1`.TO 9E PEAFORME*_' <br /> VEhl WELL r BORING(CPT_.-r C_?RC8E.HYDROPLINCH.HA 1D-AUGER.OTHER-) �t�E5iRUCTION:vER-a type:a�ws <br /> 'SOIL BORING# =-SUR- E l( <br /> �j/vY=LLrF__ RE_SUFtc GROUT <br /> 'Ot'her: <br /> COMMENTS See Attached _ <br /> TYPE OF WELLl,N/S7 aLL;iTIDN TYPE CONSTRUCTION SPECIFICATIONS <br /> 0ONITORING 1� OLLGVY STEM talc,.OF 30REHOLE Err MULTIPLE CASINGS,0 YES �'fV0 `ILE L+SAS NG D1A2" <br /> fl FXTRAC.TION a AIR X;,MMER/OR1VEN CA�!NG THtCKNESS S Ch 40 TYPE DF Cncl?1G: Q STEEL �/C <br /> a VAPOR a,1UGt ROTARY DEPTH OF GROUT SEAL 6 t '7A2MIE qtr TO BE USED: ©AUGERS t4zl c cr� 1 <br /> [I AIR SPARGE *AUSH?D1NT GROUT SEAL PUKIPED: 011fes p No (MOTE, MAXIMUM FREE-FALL DEPTH IS <br /> r <br /> Ott SORiNG. a HAND 4L1GER APPRCX.30RtNG DE PT-f Z 1 �QLTEo T RA.FF:c sox or STOVE PIPE <br /> OTHER._3- OTHER CONJICTOR CASING PROPOSED?No (;fYFS 1:5l toecifiCa[ior.s:ErFI: _�_ 1 <br /> CQNidlENT3: <br /> ee attached Figure 11 <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS h <br /> ! <br /> I t-areby Carify that I havePra:.a'?❑tlis aoplica:ion anc test t')e work wO oe co-ia in 3=01anCe'NVi Sell.:0241114-Our'.Iy O(ahanGs.State Lavis, wig R:::es ! <br /> and Reaulations of the San Ja2gtJin Corm:v. Homeowrer or i:_enseC agen-'s signawre_ettlfles;he'0%-vrljg: '•l csruy that in the performance of rhe mcrk <br /> for whine this permit is issued. !shoil not employ persons subleet to WORKERS'COMPENSATION Laws of C3l7fomia-'- '��CniraCto-s ttirnG ors �- <br /> contra c inq signature=0rtities Ute"0!lowing: 't c9r6ty L7ar rn;'e9 corformRnce rf Lhe-_vork ormhiclr this Permit i.,;issued. i Shari err.;Drcy re=ns SuAieC'tc <br /> vvoR-<E;S'C,:MPE:VSAT;CfV,-�ws of Celifomie.- <br /> THE APPLICANT MUST CALL.48 WORKING 4RS IN ADVANCE FOR ALL REQUIREC INSPECTIGNS. <br /> syn9ax__ _ t r TEtla Consultant p,.e 3/23100 <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED- <br /> R <br /> DEPARTMENT USE CNLY u <br /> AppiiCat'o^ACoeGtea gY _Cate `ssued [ —Area—,— <br /> Govt Insp^c�or By Dated -L "�� rnai Inspection 9y Date_ <br />^ <br /> Destruaion lrsoec:ion 8y pate�--� <br /> CoMMENT31 CONDITION3: <br /> ACCO',JNTINS ONLY: t rlC� <br /> 3£ZOOES I rEE INFO AMOUNT 2EMITTED I CHECK>y I R£C'D BY ' DATfi E AEPMtT,SERVICE REQUEST 4 1t�VOiCc <br /> ------ 0©� <br /> C•ii LIJCicIVSED CU TRACTOR l�:L 5T SIGH I.ICENSc 3t OR-T{ER`� CONDENSATION DEC:_AR.kTIO?N' � <br /> /stcn bkc JiMl <br /> i <br />