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09/15/99 IVSD 13:38 FAX 510 663 6550 GEONATR1X OAKLAND 0 004 <br /> fJ •' <br /> ALL PERMIT APPLICATIOfq--ir"ORM UNIT IV <br /> REOFIVEDQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISIOiN (PHS—EHD} <br /> SE P 17 1999304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209T468-3449 � <br /> ALTH <br /> nrNfM VYUNOABLE PERMIT EMPIRES 1 YEAR FROM BATE ISSUED <br /> Application is pgga>� � �arnty a permit to conahuct and/or install the work described. This application is made In compliance with <br /> Sari Joaquin County pavelo,ppment Titlo.Chapter 9-1115.3 and the Standard%ct San Joaquin County Pubilc Health Serv)cas,Environmeritat Heahh Divislon. <br /> WELL Lactation Cross Street CorYat rto6�aw City_�r2 Assessors zip Pa cegt2,32 1b—e5 <br /> PROPERTY Owner I1J.1 , �1tA11 Y15 �AddrzsePD, Rn x 1-7& —City 'F�64 Zip f_p J /� Phanoil f(x <br /> c-57 ConirseYorQ t' Addres.Rx 6,60h �'�iir_at 387 Phan�e �r231��K75 <br /> Consultant Sub Conbzctor �Ln� U. ��Phone# 10 Ya�v3'L�1CG <br /> GIS Coordinates:X 31+-7ifo� Y-[Z(- ( 7awnahip Range SecBcn <br /> WOR it TO BE PERFORMED <br /> AKEW WELL,/BORING(CPT,GEOPROSE,HYDROPUNCH.HAND-AUGER,OTHER-) Ij DESTRUC71ON(choose type below) <br /> {ISOIL BORING S 161-131b <br /> WELL# (]OVER-BORE <br /> •Otttar: Q PRESSURE GROUT <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATCON TYPE CON"",- TIOCIFICATIONS <br /> 13 MONITORING 11 HOLLOW STEM DEA.OF BOREHOLE MULTIPLE CASINGS?Q YES <br /> 0 EXTRACTION 17 <br /> Q►VO WELL CASING DIA:�� <br /> Q AIR KAMMEPMRIVEN CASING THICKNESS <br /> Q VAPOR ---�3A --�TYPE OF CASING: p STEEL 13 PVC Q QT}iER;�_ <br /> Q MUD ROTARY DEPTH OF GROUT SEAL A TREMIE TYPE TC SE USED: Q AUGERS OOSE <br /> DAIR SPARGE PUSH POINT GROUT SEAL PUMPED: Q Yes Q Nc (NOTE: MAXIMUM FREE-FALL- DEPTH IS 30'1 <br /> OIL BORING 0 HAND AUGER APPROX.BORING DEPTH_-_tq J; A' p BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> Q OTHER-'-------0 OTHERCONDUCTOR CASING PROPOSED7_tJA_(If YES,Hat speclflcationa hetst: t4A <br /> COMMENTS. ',-If) SOrf [bir!`✓J44 rs�C �.Mnl p [ - 4 yx! a t'i4f ►vela �r r L�ti> (awr riyt <br /> (apa <br /> .. .,. J <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMTS <br /> I hereby certify that 1 have prepared this appicallan and that the work will be done In accordance with Srn Joaquln County Ordinances,Slats Lawn,and Rubs <br /> and Regulations of tha San Joaquin County. Homeowner at ikensad agent's signature ratrlif4i;the fotfowing:"1 C*Pdfy That fn the jocnW"wrica of the work <br /> for whleh this Permit/n ltstrod,I shall not anWleY parsons subject to VMR)aWS'C0XPENSATi'ON Latus of CaliforWr." Contrzch2es hiring or cub- <br /> conbat ting algnature cettlfwrs the following:7 Cara /hat In the Performance zeft W**/hr rrd+ka'i this/le MIt Is/&Tuan,1 shat►art! <br /> W ORKERS'Co sa TIOAt Le" ry Ptbr persons s dost to <br /> THE APF UST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED LNSPECTIONS. <br /> 5lgnod x Tttle )Lt�"r tflnl�il YZDate <br /> SEE ITE .MAP I MIT IV WORK PLAID DATED <br /> Accepted By DEPARTMENT USE ONLY 9_/ � /9 ArcaO� <br /> aPP Date Issued / <br /> Grout Inspection gy Date Final Inspection By Date <br /> Destruction Inapectfon By Data <br /> COMMENTS r CONDITIONS i <br /> •L <br /> ACCOUNTING ONLY: AIDC} - FAC# � -- - <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK(MCASH RECEIVED BY DATE PERMIT/SERVICE REQUEST"UMBER INVOICE <br /> UNIT I1(-6/23/99/sign bkpg/MI <br />