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ri <br /> 96%' PWELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> r <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-ELIC) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-34.49 <br /> NON-REFUNDABLE PERMIT EXPIRE3 I YEAR FROM DATE 13SUED <br /> Appiicaticn is ner�,by made.a San_oaat:n County fol a cermii to construe.zndlur install:n-LY7rt descricct -his aoplicztirn's marc�r.corplianc='M:r� } <br /> 1 1 San Joa-,u;n County Development'"la.Caap'er S-1115_.3 and trio Stal(larM 31 Sar..:oaaum Co,int7?ubk Health Servroz;_ Env ronrental h2aL'h Division <br /> Assessar A 50150-18 <br /> WE_L Lor—ation 7500 W 11th Street c-oss StreeiChr:Lsman RRrlrjril Trar4 z:B 95376 parc_-14 <br /> Carl & Annamae Navarra 475 W Blewett cryTrac <br /> PROPERTY Oviner A4drevs _____y__Zi?95375 Phcr:eg(209) 836-0005 <br /> Spectrum Exploration wam <br /> C_57Crntr.C1or Address 2365 Wi g eit�tockton?;p95205_'---k12268Phc:e<Z_q) 46-5--8712 <br /> The San Joaquin Company 8617 Etcheverry. .} Tracy �.� P,,o eY(209) 832-2910 <br /> Consultant;Sub Contractor ^ddl._ <br /> GIS C�ora.nates:)t .Y Townsnio Range Secdor <br /> WORK.TO BE PFRFORMEr.- <br /> 1/r4E'/J WELL r BGRING(CPT. EC-RCBE. HYOROPUNCH.HAND-AUGER.OTHER') 3 DESTRUC.TI3N(_ha>se,,,pe oe awi� <br /> Ir COIL BORING# VER-BOP.E <br /> �JVELL f*-- <br /> RESSURE GROUT <br /> `Ocher: <br /> y COnnMEVTS: See Attached <br /> TYPE OF WELL INSTALLATION TYPIC CCNSTRUCTION SPECIFICATIONS <br /> 6" -MULTIPLE CASINGS%a YES 40 `hE_L CASING DIA-2"- <br /> 3,�dONITOAtC1G '�!OLLGV7 STEM DLA.OF BOREHOLE -_ <br /> a FX-RACTION 0 AIR! A.MMERIDRIVEN CASING THtCKNESSSch 40 TYPE OF CAGING: a STEEL Uk.'/C 00, cR: <br /> a VAPOR a MUD ROTAFY DEPTH OF GROAT SEAL 6} TZEt4tlE i IPE+OBE USc7: Q?.UGERS <br /> a AIR SPARGE VL'SH POINT GROUT SEAL PUMPED: Heyes a No INCITE: MAXIMUM FREE-FALL DEPTH IS :,Q) I <br /> IoGIL BORING. q HA14D AUGER APPRCX.30RING DEP-ri 21' ►R'60LTED TrRA.FF=i BOX oC 0 STO`JE PIPE <br /> i a OTHER. a OTHER CONDIiCTOR CASING pRopOSED? Na (;LYES last soecificxions�L.ere): _- <br /> I <br /> COMMENTS: See attached Figure 11 I <br /> I <br /> Fl. NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I t-erecy cavity:tial I have pre?a'-ia this anplicatiCn Inc thst tate work WH oe Pane in a=Mance wire San,:oaauin County OrdLaws.St3te and <br /> and RevuWtions of the San Jcaauin County. Homeowrer or;;censed agent c signatureC.ea!fies the Tol.r.wing: -r certify that in the pentrmarce otrhe'wcrk <br /> for which this permit is issuod- .'shall not employ persons subiect to WORKERS'COMPENSAT70N Laws of C3idfomia." Contracto's nir riq or s_t- <br /> f CcntraCting$ir�"SatUrO certifies t1e ro'-lowing: 'r c9rtity&at:n.'79 aedor.:tance r,!me work or�•ihich 1171-S permit i:;issued- i shah err.!ny�r•z�ns suj!3,eC:.10- WORKErS'COMPEaSATION Laws o:California.' <br /> THE. <br /> /A/PPLI AN i MUST,CALL 46 WORKING!-IRS IN ADVANCE FOR ALL REQUIRED INSPECTIGNS. <br /> S>zned x !7 . r 71tle D2.e 3/23/00 <br /> Fill <br /> SEE SITE MAP IN UNIT IV WORK PLAN DA TED: <br /> FilDEPARTMENT USE CNt_Y C) � <br /> Apokat°o-.Acceetea9y' __ Date's3LGd" LI pv r.fC3_- <br /> G-outinspecvor$y_ A,�AdAr_0— —Dale 41 'L —'a 00nal InWection Sv+ Dale <br /> Oestruction irsoec6on By DateF1 — <br /> COMMENTS 1 CONDITIONS: <br /> I' <br /> k, <br /> 4CCOUNTIN;,ONLY: l Alt:x <br /> °E "ODES FEE INFO AtAOJNT REMITTED I CHEC'A# ; RI~C'0 BY ;I DATE � PE?MIT i SERVICE,REQUEST At � ItvVOICE <br /> 7 So � ; �qD I _ 1 ysF# Dd Zz-SoSJI. <br /> C-57 LICEPASED COLNTRiILCTOR 12UST SIGH"LICENSE&1'V S` CO3NWE�TSATION DEC:ARiTI�` <br /> UNT-`T`1 -6/2 39 !sign hkbciMr <br />