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NONREFUNDABLE PER, <br />.AIT F-XPIRES ' YEAR FROM DATE ISSUED <br />Appicaticn is herb's made :o San _ziaqu:n :ourty for a permit to construct and/or install the wore descriced This aoplicz!ion ,s mace ir compliance gra` <br />San Joaquin <br />County Oeva.Iopment 'le Chaplet 9.7115.3 and the Stanaaras of Sar Joaau,n County ?ub!ic Health Services. Env ronrental Hsal'h Division <br />q W 11th Street r� Tracy z A pa �, uc .S 0 a' % <br />WE_L Locution 7s O Coss Street Chrisman Rtt/ Tr <br />— t�' — <br />avarra <br />PROPERTY Owner Carl & Annamae - ' xi;Eress 475 W Blewett Ed -City Trar Zic�—Phcr,e# - 05 <br />Exploration 2365 Wigwam Oil�tockton„p 95205_5 2268Ph,;rez(209) 465-8712 <br />C-57 Cnntrctor Spectrum Address - — — <br />Consultant: Sub Contr2ct.T1,e San Joaquin Co -Address 8617 Etcheverryc,ty Trac _ 10 <br />GIS Caord.nates: <br />`l <br />WORK TO BE PERFORMED <br />9/1JE'N WNELL / BORING ( CPT, EO�RCBE. HYDROPUNCH <br />SOIL BORING # <br />lltv�iELL d <br />Townsnio Range <br />HAND -AUGER. OTHER`) <br />Sectior <br />'] DESTRUCTION (choose type oeiow) <br />Q CVER-BORE <br />--- DQE=SURE GROUT I <br />'Other: aC <br />COMMENTS: <br />See <br />AONITORING <br />�%'OLLGNY STEIW <br />EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />VAPOR <br />a IUC ROTAFY <br />yl <br />'e-USH POINT <br />VSCIL BORING. <br />O HAND AUGER <br />U OTHER. <br />OTHER <br />> <br />N <br />U <br />G'_ <br />�) <br />WELL PERMIT APPLICATION FORMUNIT IV <br />W! <br />LJJ <br />5!~ <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />$$ ¢¢ <br />'C LL <br />CE <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHC) <br />I <br />, a� <br />304 E. Weber, Third Ploor, Stockton, CA., 95202 <br />.' <br />(209)468 -3449 <br />NONREFUNDABLE PER, <br />.AIT F-XPIRES ' YEAR FROM DATE ISSUED <br />Appicaticn is herb's made :o San _ziaqu:n :ourty for a permit to construct and/or install the wore descriced This aoplicz!ion ,s mace ir compliance gra` <br />San Joaquin <br />County Oeva.Iopment 'le Chaplet 9.7115.3 and the Stanaaras of Sar Joaau,n County ?ub!ic Health Services. Env ronrental Hsal'h Division <br />q W 11th Street r� Tracy z A pa �, uc .S 0 a' % <br />WE_L Locution 7s O Coss Street Chrisman Rtt/ Tr <br />— t�' — <br />avarra <br />PROPERTY Owner Carl & Annamae - ' xi;Eress 475 W Blewett Ed -City Trar Zic�—Phcr,e# - 05 <br />Exploration 2365 Wigwam Oil�tockton„p 95205_5 2268Ph,;rez(209) 465-8712 <br />C-57 Cnntrctor Spectrum Address - — — <br />Consultant: Sub Contr2ct.T1,e San Joaquin Co -Address 8617 Etcheverryc,ty Trac _ 10 <br />GIS Caord.nates: <br />`l <br />WORK TO BE PERFORMED <br />9/1JE'N WNELL / BORING ( CPT, EO�RCBE. HYDROPUNCH <br />SOIL BORING # <br />lltv�iELL d <br />Townsnio Range <br />HAND -AUGER. OTHER`) <br />Sectior <br />'] DESTRUCTION (choose type oeiow) <br />Q CVER-BORE <br />--- DQE=SURE GROUT I <br />'Other: aC <br />COMMENTS: <br />See <br />AONITORING <br />�%'OLLGNY STEIW <br />EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />VAPOR <br />a IUC ROTAFY <br />Q AIR SPARGE <br />'e-USH POINT <br />VSCIL BORING. <br />O HAND AUGER <br />U OTHER. <br />OTHER <br />CONSTRUCTION SPECIFICATIONS ` <br />DIA. OF BOREHOLE MULTIPLE CASINGS, ,�' 0 YES �10 `A,E_L CASING DIA' 2” ._ <br />CAS!NG THICKNESSS ch 4-0_ TYPE OF CASING. 3 STEEL V/PVC 0 C"'Ft=R: <br />DEPTH OF GROUT SEAL 6 'RE!AIE TYPE TO BE USS:)! Q AUGERS QKOS-c <br />GROUT SEAL PUMPED: les p No !NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />21' �OLTED TRA.FF:C BOX or p STOVE PIPE r <br />APPRCX. BORING DEPTH — <br />CONDLCTOR CASING PROPOSED? No (;f YES I sl soecrFcatiocs .err<1:_ _- <br />COMMENTS: See attached Figure 11 <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br />I rerery car+/ !hst I have prapare.o tris aopiicaticn anc tMit the work wi;l oe :one in acccmance 7t'^ San ,oacuin Courcy Orainances. State L3WS, 3m! RL;: --s C <br />and Regulations of the San Jcagwn County. Homeowrer or i tensed agen• -e signa;cre ceR!fieS the 'ol:cming "t certny that in the perrormarce of the tvcrk <br />for which this permit is ISSUED. !shall not employ persons subject to WORKERS' COMPEYSA TION Laws orCaflrornia.' .'ontracto's hidng or s_b- <br />ccntracting signature certifies the `o!lowing: " f cer tf t"at :n 'he oe:forrnance _.f t.�e work'orvAich this eermrr iA issued. i shaft sn^^'ey persons Sub;eC' re <br />wORKEPS' COIWPEIJ`:ATiCN _s.vs of California.' <br />THE /�' APPLICANT MUST CALL 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIGNS. <br />signed X <br />/ el Tula Consultant Da!e 3/23/00 <br />',"" 1 <br />SEE SITE V IIAP IN UNIT IV WORK PLAN! DATED: <br />DEPARTMENT USE ONLY <br />Appiicato' Acceatea _Date 'ssued Oc% Area_. <br />Gout Inspector By Iil�,,tiMAr&A. Oate`'I 'Z '71 -final Inspection By Do'8_ — <br />Destruction ir,soecrion 8 Date <br />COMMENTS / CONDITIONS: --.-- <br />ACCOUNTING ONLY: ; AICA <br />gE CODES I FEE INFO AMOUNT REMITTED � CHECK !1 1 REC'0 BY DATE <br />C-37 LICENSED CO:NTKNCTOR lr1UST S1G3NL10ENSZ SC VNK�`- <br />UNI' I'd - 612':,"30 /sicn bkc;iML <br />PE; MWT i S- T !t I INVOICc <br />�Ral-I SD� — <br />�• � RiTIL` <br />