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3LNT BY:9163622318-Sacra. , CA 23- 0 : 1 10PM :RADIAN li\TaNXT1 ` L <br /> WELL PERMIT APPLICATION FORM Ubt <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 96202 <br /> (209) 468-3449 <br /> •'ON REPUNDA%&PERMIT EXPIRES 1 YEAR FROM DAT -999 <br /> Application is 10reby made to San Joaquin County fora patmb to 00,11mrol enww 1113011110 work Msrnbed, <br /> San Joaquin County Developroont TRle,Chapter 9.1116.3 and the SOndarda of San Joaquin County Pubic Heelth <br /> WELL Lo=ucn Dj�rc' �OCQO71�JnAC rola Street <br /> PROPFRTY Cwner/ '6" L' `Fai J•v s ,SCh ��`Rea!1,°P"rSJK6,f <br /> 9(�Od ! D. <br /> C-ST ConbaUor fC Il Addteaa )6 Avis a L6,fP <br /> Cp,q,gq,g19a0fieesradorUSS re /%Ir �i.,I I' Redress -3(SCl <br /> OIS CoorXdinalea:X a 1���1`] Y �°3 2 ZZ- ownshiP <br /> WORK To BE PERFQRMED �C <br /> NEWWELL f BORING(CPT,GEOPROBE,HYDROPUNCH,HAND•AUGER,OTHER*) p DESTRUCTION Icroose iyPt`9.,.'_ C <br /> aS01 L BORING M p OVER-BORE <br /> SOI WELL it pPRESSURE <br /> 'Dow: 7k <br /> COMMENTS' <br /> TYPE WELL ly,$TALLAT SPE 1!!N9TRUCTION$PECIPICATIONS <br /> p MONITORING 'QoLLOW STEM DIA,OF BOREHOLE I -_MULTIPLE CASINGS?p YES a NO WELL CAS''-= -- <br /> �XTRACTION p AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: Q STEEL p PVC p OTr! -_.. <br /> p VAPOR p MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED B AUG= 4 C <br /> p AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPe4:�iaa p No {NOTE:MAXIMUM FREE-PALLQ- <br /> p SOIL BORING p HANG AUGER APPROX,BORING DEPTH, 13t) p ROLTEC TRAFFIC BOX or <br /> 07HER n OTHER CONDUCTOR CASING PROPOSFA7 (If YES,list specificati;ns has.' <br /> COMUENTS <br /> NOTE: OFFSITE BORING$ REQUIRE ACCESS OR c"'- - - <br /> I haraby certify at I have pnepared(his applIcAon and that the work will be done In accotdanco w - <br /> and Regulations of the San Joaquin County. Homeowner o9rsanaed a to e yiVOil R!(ERS'CO►f*5 the TICr!'� <br /> for which this permit!!issued.I shalt not employ pari bJec! <br /> contrading signature Wntifiea the f liOwing:'I canny that in the pedormence of the work for which this pennr,s - <br /> eyDRKERS"COMPETlO c7 CaNfomla..^ " T�„ <br /> Signed Y ow 7199 FDate___-... <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED: <br /> DBPARTMENTUSL'ONLY <br /> ApplicL rc <br /> allon Accepted By Dace Issue B ^.__ <br /> Grout Irwpedlon By <br /> Daie Final Inspection By <br /> Destruction Inspection By Date <br /> dAi t.Q.LLC'Vat <br /> COMMENTS/CONDITIONS: � W _. 1 <br /> ACCOUNTINGONLY: AID! _....___. <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK* REC'D BY DATE PERMIT I SE%:7Cc <br /> i SSP 8 4" Bq lug 6 od sr� .0-69 -6 z <br /> UNLT IV-6123/99 hign WryyJMI <br />