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Applicaton Accepted By
<br />Grout Inspecti3n
<br />Destruction Inspection By
<br />COMMENTS I CONDITIONS:_
<br />AID#
<br />tow
<br />ACCOUNTING ONLY•
<br />PE CODES FEE INFO TAMOUN1 REMIi.D CHECK It
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<br />g47 °° 1 0
<br />01a MI 1 Al'
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<br />C l•ICENSED CONTRACTOR:MUST SIGN.,.L1
<br />UNIT IV - 6/23/99 /Nip bkp9/MI
<br />NSE &WORKER.. ,LARATION
<br />P RMIT d qPnvICIEAL,C4ES 1 INVOICE
<br />SEIPT BY: SPECTRUM EXPLORATION; 9-21-99 14:38; 2094658773 209 838 9883;
<br />WELL PERMIT APPLICATION FORM
<br />
<br />UNIT IV
<br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES
<br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD)
<br />304 E. Weber, Third Floor, Stockton, CA., 95202
<br />209) 468-3449
<br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DA re 13kp
<br />Appikcation i hereby made to San juoquin County for a permit to construct arid/or install the work described This application is made in compliance with
<br />San ,Iaaquin County Development Tide, Chapter 11 • 111r, 3 and the Strtnrlards of Sao Joacatin County Public, Health Services, Environmental Health Division
<br />WELL Location 0)00 k 6.10 99 Crosi Street Er2rfarktikn 0 Oily .. l'ArD4Zik bp .../94?—..,TA.Ze 65--ago-t I ___ _ _.
<br />PROPERTY Owner t'._,e,1-1-0 Address ..-7(41....!.....ANf.:PrrA,, af:City C411C..gier% Zip 9 VaPh 0 nett (-141,,,077 .........
<br />C-E7 Conifetztor__ ffINNN Address, ?-3.(15- ot.1.40%-1 cit y S-kaolz,p 7DAT„-1240 ,,„„00 ,fles--,g7 t2.. .....„. .....
<br />Consultant/ Stib Contrapter_&r.:0 .... ?CIO Arokiyaress 171 9 HAL021 coyaetiont.,„#06t, none# . ' .--- 4111C ig2W, /Ca g'
<br />GIS CoordinatOS. X
<br />WORK TO BE
<br />C NUN WELL BORING 0,0:1PR0HE, 11YDRO.e.yNcy, HAND-AUGER OTHER' n911.. BORiNG #
<br />NACU # t 201,....M
<br />'Other.
<br />COMMEN75*
<br />I ownship., 42.1U Range Seet1011
<br />fl DESTRUCTION (choose type below;
<br />OVER-BORE
<br />11 PRESSURE GROUT
<br />TYPE OF WELL
<br />pONITORING 1-1
<br />EXTRAC'l ION
<br />['VAPOR
<br />a AIR SPAROF
<br />X5011 DORING.231-5
<br />OTHER:
<br />INSTALLATION TYPE
<br />,HOLLOW STEM
<br />0 AIR HAMMER/DRIVEN
<br />O MUD ROTARY
<br />a PUSH POINT
<br />0 HAND AUGER
<br />11 OTHER
<br />CONSTRLICTIOtiSPECIFICATIONS netot
<br />DIA Of.: BDREHOLE.0". /%," MULTIPLE CASINGS? 0 YES XNO WELL CASING DIA ot
<br />CASING THICKNEssSen- 40 TYPE OF CASING )0.vc: go THER
<br />DEPTH OF GROUT SEAL 0-5-P) REMIE tYPE 1•CL BE USED 0 AUGERS
<br />GROUT SEAL PUMPED Nif es a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30')
<br />APPROX BORING LX:Piti j(E301., TED TRAFF Y(7. BOX of Q STOVE PIPE
<br />CONDUCTOR CASING If YE5 .11513PeciFcatIons hole
<br />COMMENTS: MUJ qtrtita731(011 _164.4 kto.)..-mwt4 w2N,17-1.c.
<br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS
<br />I hereby certify that prepared thii‘ application and that the work wd be hone in accordance Y4th San Joaquin County Ordina717.:cs Mate LaWS. and Rules
<br />and Regulations of the San Joaquin County. Homeowner of keansect agent g signature certifies the following , ,y certify that itt the performance 00 the wor k
<br />for which this permit is issued, I shall not elnpfoy persona subject to WORKERS COMPENsAncm Lw f Cdllfo,nja.' Contractors Ming Of sub-
<br />contrectinc, signature oettifies the foflowinty '') eattify that de tee perforyttanr:e,of rrre work for wrvoh this oitiMit L 43siOci, 1 ;grail wilpky per:5onN :51.'0x:fro
<br />WORKERS' COMPENSA 770N Laws of Ceirfoarie '
<br />THE APPLICANT.MUS1.CAtL.4111NORKINGI14R$AN.ADVANCE..FOR:ALL..REQUIRED,INSPECTIONS.
<br />To. CA. mjs- Date 7PAM
<br />SEE SITE MAP IN UNIT IV VVORK PLAN DATED: \it-ove.
<br />Signod x
<br />u-0......ria_PEPARTMEN1 USE ONLY
<br />Dele Issued C 21- I STe"
<br />Final Inspstction By Date
<br />Date
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