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9-22-1999 A:BBPM FROM <br /> 11Ald <br /> WELL PERMIT APPLICATION FORS <br /> UNIT IV <br /> SAN jOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION ("PHS-EHD") OCT 0 3 2002 <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 . <br /> (209) 468-3450 ENVIROM,,IIENI HEALTH <br /> PEUJMSERVICES <br /> NON-REFUNDABLE PERtvt1T EXPIRES 1 YEAR FROM DATE ISSUED <br /> is <br /> cation is <br /> de in <br /> ance <br /> th <br /> Application is hereby made to San Joaquin Coup'forts 3ermit to the construct <br /> and rds of San Joaquin County PuCl l l�h�'Se^`'`r EnwonmanEal Healkh Di�s nn: <br /> San Joaquin County Development Title.Chapter 9 9 AssParass0r0-4 °I�y 90 -01, <br /> 7q 'Ra•J /4 [- L- cit S TP—WELL Location i IO tin L.K�S4c/4�<.- Cross Street t s•. Y <br />' ff .,u.er ,x <br /> PROPERTY Owne �• C�..S�'orlc.�ry., zip 95c'tLIJ Phone# <br /> r_ Oh rn 1 i1 ddres5,7`lid <br /> 73 Licc#4,85145 Phoneit�S� <br /> 17 r.1 i tit Aress o asdc Cit<f k� Zip _ <br /> C-57 Contractor�. ��--� dd <br /> 2" <br /> Consultant <br /> �o tac# �--phoRs# 07- 33_Z36 9 <br /> ,�virpn^�^' Address .r <br /> E Consultant *a' r Section <br /> GIS Coordinates:X <br /> Y Township Range <br /> WORK TO BE PERFORMED <br /> " p DESTRUCTION(chaos type below) <br /> NEW WELL 1 BORING(CPT,GEOPROSE.HYDROPUNCH.HAND-AUGER.OTHER') 13 OVERBORE <br /> SOIL BORING Q PRESSURE GROUT <br /> [�WELL# <br /> •Other. <br /> =AMENTS: <br /> f PE 0 L CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS Y NO WELL GASING DIA <br /> MONITORING U HOLLOW STEM DIA.OF BOREHOLlr Z MULTIPLE CASINGS. : ES PVC a OTHER: <br /> TYPE OF CASING: STEEL 0 Kr n&-;c r_puc. <br /> EXTRACTION []AIR f 1AMMER/DRtVEN CASING F GROUT <br /> HOSE <br /> rJ L 3 S TxE�fIE TYPE TO BE USED: ,i�A� Q <br /> I]VAPOR q MUD ROTARY OEPTri OF GROUT SFA <br /> PUSH POINT GROUT SEAL PUMPED: (j Yes t3 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30'} <br />+ G AIR SPARGE rBOLTED TRAFFIC BOX or .a STOVE PIPE <br /> SOIL BORING (] HAND AUGf-R APPROX. BORING DEPTH . 3 S —13 <br /> 1orclG C CONDUCTOR CASING PROPOSED? (if YES, fist specifications here): <br /> a <br /> OTHER: CON <br /> , <br /> COMMENTS: SIM-- <br /> EQUI <br /> RE A SS OR ENCROACHMENT PERMITS! rM. <br /> NOTE: OFFSITE BORINGS R <br /> work <br /> I Hereby certify that[haven Joaquin Countcalionand that lie jivini''K %611 be 00%-��11.50c 01"Clarice <br /> y.Iltiameowner or lk ens d gent's signature certifies the tfollowing-."�I certify that it)the performance��Rules <br /> b- <br /> and Regulations of the 5 QwS of <br /> for which this permit is issued, <br /> I shall <br /> noYf certify that in the performance oI tp#oy persons subject to %, forO�Ph this pemtit is issued,I hdmsmaloy persan5 s410W . <br /> sucontracting signature certrf: following* <br /> WORKMAN S COMPENSATION Caws Of CafifOrnia." <br /> TFi PPL}CANT MU5T CALL 48 HRS W AD FOR ALL REQUIRED INSPECTIONS. <br /> fro/1U g ' tri' <br /> 4. Signed x <br /> SEE SITE MAP IN UNIT IV WORKPLAN DATED 6 1 oZ <br /> DEPARTMENT USE ONLY <br /> Date Issued ea <br /> Application Accepted By Date <br />} Grout Inspection By <br /> Date O Z Final Inspection 8Y <br /> destruction Inspection By Date ( C <br /> I COMMENTS/CONDITIONS: L <br /> FAC# <br /> ACCOUNTING ONLY: AID# <br /> I <br /> PE CODES FEE INFO AMOUNT REMITTED CHECI(ftlCASH RECEIVED BY DATE PERMITISERVICE REQUEST'NUMBER INVOICE <br /> 3So <br /> S ,na <br />