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TP 209_-465_U.f tJ ' <br /> Feb 06 0 02: 3GP Brenda 7indell y ! <br /> 0-go TLE13:43 FAX 1925958 EAKR'EST WCZ002 <br /> I <br /> Y <br /> WELL PERMIT APPLICATION FORM _ UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> • ENVIRONMENTAL HEALTH DIVISION (PHS EHD) <br /> 304 E Weber,Third Floor, Stockton, CA., Si202 <br /> (7019)as84"9 <br /> MON�F1JiiDQOLE P PI 1 YEaR F13OY GIATi! <br /> AppNeatm is hereby Made to San Joaquin Count'fpr a pamfitto construct andrat instaflths wok d�scxlbed.I�Tnls appliCStion is mach in PArgpllaRCB with <br /> San Joaquin County Development Tide.Chaptet 9-1118 3 and the Standards of San Joaquin County Public P eBith Services,Environmental Hesith Division. <br /> t+MELL Lrxatlon 13___7_S�ewl 1515 r�tWcVW Alt—streak Cay �� �+'ti a p s <br /> eoni,dfsntrswubrfo+titreeror I l '�" � es _ Sl�r�rt`y_ �pfr ?J.► PhonPROPERTYOn,& anxat ju IRtjS40" l <br /> 507 <br /> a 11 � �City ?�OS- y6r"ZC47 Contmdor Phor"ogddres77 Ae` r. C' <br /> 1 <br /> CYI3 Conrdiratee:X Y Towntlhip Rtrrgi ! Section <br /> WOM <br /> TQ <br /> t 11 NEW WELL r BORING(CPT,GEOPRORE,HYOROPUNCH,HAND-AUGER,OTHER') DESTRUCTION(choose type below) <br /> D SOIL BORINGS s <br /> a WELL 3tZIRESSURE GROUT <br /> 'OtlM►: I} l <br /> COMMENTS: ii p <br /> gQHjTdWTPR CENOWk <br /> NILMOWTORING a HOLLOW STEM OLa OF BOREHOLk-MULTIPLE CASINGS1,Q ITS U10 WELL CASBKS DLI: <br /> OIEKTRACTION o AIR HAMMEWDRtVEN CASING THICKNESS.TYPE OF CASING: p STEEL fl.PVC 11OTHER: <br /> I)VAPOR a MUD ROTARY DEPTH OF GROUT SEAL l�TREM4 TYPE TO 8E USED: p AUGER5E <br /> } a AIR SPARGE 13 PUSH POINT GROUT SEAL PUMPED: p Ybe Q No (NOTE:,MAXIMUM FREEFALL DEPTI$H 30') <br /> Q SOIL.BORING 0 HAND AUGER APPROX.BORING DEDTH �? Q BOLTED TWFC 80X oP G STOVE PIPE <br /> a CrTHER, -- n GONOVCTORGASING PROPOSED? (It YEB,Ilat spedflCabons bore): <br /> COMM OTS: 114 /O s. SP-L 4; 'h nMr- Taw- <br /> 5 <br /> Ron Z <br /> OTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> tit* at I have pr"%d 11118 oMPmtipn end that the work VAII be done In acm4arwe with San oaquinrunty rdrnancea. a Uwa,and Rut" <br /> and Repufatlant of the San Joaquin County_ Homeowner or Ilosnsed apenYe aWtellure certN4es the iftaowinQ:&I eanyly thpt Fn the perftmlamv of me rwrt <br /> for whfth 11!13 permitla hNKM ,f Shatf rrot erripfaY ppscons WNW tp yY0MfVPS'CCWPL'P4$ATMN Lim of Carlfionda." Cw*wjes hiring or sub. <br /> eontreeting stonsture*VMS$the Wowing:11 certify thef rrr the perfan?aaco of the ww*rbc which Ihrs penrt►t,rs is"Wd,1 aharr amprvy pwaons subjevi to <br /> ! WDRKERS'C0*VNSA770N Laws of CWfomra- 11_ p _ <br /> PN <br /> Stan"x This w!r a i Dile O� O r <br /> I <br /> I <br /> SEE SITE All P IN UNIT IV WORK PLAN DATED: <br /> MMARTM a L%r OWY ;i <br /> A*Icaftm ""o T d <br /> � aea o1"u"I �1 "I r d P <br /> L <br /> orae b»peebon By Oats Fir1a)fian BY 'i pew- <br /> Deefneotlon I Cstle !�� <br /> COWEI�'B l tJOMDtT'1pN3: _ i� ;, <br /> ACGOW'lMO ONLY: ADP <br /> 111 ISE"WO AMOUNT REINi't'oJ>:C OMCK• Imo- REC'17Illy DATE !� PERliNT r mwAriC.E itEt]UF�T A INVdICR <br /> UNIT V-6/23/99 J"nbkp AAA- <br /> :Il <br />