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' .rNSMISSION VERIFICATION REPORT <br /> TIME 03/14/2000 15:28 <br /> NAME FIFTH FLOOR <br /> FAX 2094683433 <br /> TEL 2094683433 <br /> DATE,TIME 03/14 15:27 <br /> FAX NO. /NAME 919167819357 <br /> DURATION 00:00:36 <br /> PAGE(S) 01 <br /> RESULT OK <br /> MODE STANDARD <br /> ECM <br /> 4v�-X-e.k cn-� o.� ry_.�w��C 0o z Z 02,4 <br /> J <�o �j© <br /> / 1—GAS-2000 3: 1033AM FROM p. <br /> J / <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 3034 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 458-3449 <br /> NOCK-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSU50 <br /> Application is hereby made to San Joaquin County for b permit to construct and/or install tho work desan'bed. This application is made in compliance with <br /> San Joaquin County Development Title, Chapter 5-1115.3 and the Standards of San Joaquin County Public Haalth Services, Environmental Health Division, <br /> f L Assessor's <br /> WELL Location- ! (ic�'1�<L lam_-� Cross Street`� +" City Zip. Parcel# <br /> PROPERTY Owner Wr.nlee NOW t-k _ _Addrezz,00 Drr proit City a <br /> G-57 Contractor 11 tII U tc��n y . Address_ <br /> Consultant 1 Sub Contractor .GTLA) aC Jny Address_ 7 _'�,C � /!� c,..Ctty�_ipt fi Phone# / 7 'f SG+r,4, <br /> R G, <br /> GIS Coordinates;X - y Township Range Section <br /> YYC►RK TO BE PERFORMED <br /> 11 NEW WELL 1 BORING(CPT, GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER") )pES'TRUCTION(choose type below) <br /> Q SOIL BORING# p OVER-BORE <br /> Q WELL# K <br /> _ PRESSURE GROUT <br /> 'Other-, <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ��``^ <br /> XMCNITORING a HOLLOW STEM DIA.OF BORLHOLE��MULTIPLE CASINGS?I}YES Q NO WELL CASING DIA-AA <br /> 0 EXTRACTION p AIR HAMMERIDRIVEN CASING THICKNESS x ?I TYPE OF CASING: Q STEEL O PVC O DTHER; &4 _ <br /> U VAPOR 0 MUD ROTARY DEPTH OF GROUT SER d TREMIE TYPE TO Be 0ED: 0 AUGERS ui�OSE <br /> p AIR SPARGE j]PUSH POINT GROUT SEAL PUMPED, 'VYes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING ©HANE)AUGER APPROX. BORING DEPTH—.air_ p BOLTED TRAFFIC BOX or p STOVE PIPE <br /> 0 OTHER:_0 OTHER CONDUCTOR CASING PROPOSED? {If YES, list specifications here): <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby certify that I have prepared thls appllCation and thatthe work will tie done In" ordsnoe 1415 San Joaquin County Ordinances, State Laws.and Rules <br /> and Regulatlona of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: "I esrflfy that frr tftis perd'orrrrsrrco ofthe work <br />