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AUG 05 '99 1654 FR LFR LEVINE FRICKE 510 652 4906 TO 12094693433 P.02i05 ,k y <br /> WELL PERMIT APPLICATION FORM in COPY <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES Q <br /> ENVIRONMENTAL HEALTH DIVI51ON ("PHS-END") <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 L•V' <br /> (209) 468-3450 Co _ 27 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 4pplication a hemiry made to San Joel County for at Permit to Wr C andfor install the work described. This applkamn fa made w comp!ianoe with <br /> San Joaquin County Deveiopmerd Title,Chapter 41115.3 and the Standards of San Joagum County Pubic Health Samos.Environmental Neatth TO�Ni/s�b�n�. <br /> QQ rr-� n� �FtrwJ ��(N(1__rr Zk Pe-n.e1 rwn i/ Qfsr�r'OroaG �rG ASses5oY5�• Il�.+�.lJ <br /> NELL Localdm' 9�(C—ren—a�t71t7�I1ry]�Cross Street(i,rrr.r~$ A. City Iratn _- Zip PerreM <br /> PROPERTY Ownerli ( ....dy . 6wAax Address Qty—Tp Phone/ <br /> SJ_ <br /> T-57 Comm,,%w fiYrrae..•- Address ZTcS Ahl. -^ L3e. City = Zip 1'tz UcX SrizbN Phonetrto-J�6r-67/Z <br /> :onsuaatri l Sub ComraG ZC&. (f, AKtG Address /9e0 4w&c jr,, /t F< gry,E.hcayHeviLes Phonea(S/Ai51f-7607, <br /> ,IS Coordinates:X y..Tdwnship Range Section <br /> NORK TO BE PERFORMED <br /> 504EW WELL 1901(CPT.GEOPROSE,HYOROPUNCH,HAND-AUGER,OTHEll 0 DESTRUCTION(Choose type trelew) <br /> -0-SOIL BORING a <.�� Ci./1 a OVF3b80RE <br /> O WELL a — O PRESSURE GROUT <br /> 'Omer. <br /> ^OMMENTS <br /> TYPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br /> J MONITORING HOLLOW STEM DIA, OF BOREHOLE (-n,.cp MULTIPLE CASINGS?O YES D NO WELL CASING OLA <br /> 3 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS v TYPE OF CASING: 0 STEEL O PVC 0 OTHER <br /> J VAPOR p MUD ROTARY DEPTH OF GROUT SEAL o-pa Bcr T REMIF TYPE TO BE USED: ArAUGERS OHOSE <br /> 3 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: $ryes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS ZD') <br /> XSOIL BORING O HAND AUGER APPROX.BORING DEPTH ,36-�i YY & O BOLTED TRAFFIC BOX or O STOVE PIPE <br /> 3 OTHER CONDUCTOR CASING PROPOSED?­dVC._(ff YES,let specifs tior s here): <br /> COIIIMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS! <br /> hereby car"that I have prepared the application and full the woes will be done In a=rdance with San Joagwn Courtly Ordinances,State Laws.and Rules <br /> utd Regulations of the San Joaquin County. Ho naowner or kensed agent's signature eeRifies the following_'I curly that in the Performance Of fire wwlr <br /> for which tris pill Is Issued.I shall oaf employ persons sub/wt to WORKMAN'S COMPENSATION Larva of Cel/fomra.' Cont=Wes hiring or wb- <br /> b.0 Clamg signature ranifias the toji g_•1 certify that in the performance o1 the worn for will this Peni is issued,I shelf employ Persons subject to <br /> WORKMAN'S COMPENSATION Lsws of California.' <br /> THEE APPLICANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed z <br /> rN /-R <br /> e IL;"% e5Gdrvs.rr Oahe 07699 <br /> SEE SITE MAP LN UNIT IV WORK PLAN. DATED <br /> DEPARTMENT USE ONLY <br /> "imGon Arrapted By Date Issued tr[[ / <br /> ,grout Inspection By Date Final Inspecuon By Date <br /> 7estruebon Inspection By Date <br /> COMMENTS 1 CONDITIONS: <br /> FACS <br /> ACCOUNTING ONLY: AIDS <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKaVCASH RECEIVED BY DATE I P£RMITISERVICE REQUEST NUMBER ; INVOICE <br /> ACT IV-5/99/All <br />