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CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE MULTIPLE CASINGS? 9 YES 9 NO WELL CASING DIA: <br />CASING THICKNESS <br />DEPTH OF GROUT SEAL <br />GROUT SEAL PUMPED: a Yes <br />APPROX. BORING DEPTH <br />CONDUCTOR CASING PROPOSED/ <br /> <br />TYPE OF WELL CONSTRUCTION TYPE <br /> <br />ip<AONITORING HOLLOW STEM <br /> <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN <br />VAPOR a MUD ROTARY <br /> <br />3 AIR SPARGE 9 PUSH POINT <br /> <br />0 SOIL BORING 9 HAND AUGER <br />OTHER: <br />TYPE OF CASING: 3 STEEL ,A4VC 9 OTHER: <br />TREMIE TYPE TO BE USED: 9 AUGERS OHOSE <br />No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30');r. <br />OLTED TRAFFIC BOX or 9 STOVE PIPE <br />'if YES, list specifications here): <br />rw, <br /> <br />WELL PERMIT APPLICATION FoRM UNIT IV <br />CrD <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION ("PHS-EHD") <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3450 <br /> <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> <br />Application is hereby made to San Joaquin County for a permit to construe and/or install the work described. This application is made in compliance with <br />San Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />Assessors <br />WELL Location c.2?-3C1 3 '6 )--)td-4-f ( 32— Cross Street City Nur it J Zip -)5-3?6---Parcet# <br />PROPERTY Owner 74-/-6raid- a -ce€44---). Address 126 212 .?. CVe411A/e4-t: 15 Zip %----1-:'hone# 6° 1'3 4496' (7/2 <br />C-57 Contractor /0-(Mit.c.47 CQ--677 IS) Address "YOZAS AI . ) t.- (--70/ity cYCLAINIta, q'3ZitreS/-abZ2:7Phone# 411(2 7 —/CZ) (9 <br />Consultant / Sub ContractorWeS1-04z Mari- Address22 2°'1q,'" Of-City ee4AI2hx) Li P-75 PhoneeiP &36,— --727 <br />:3IS Coordinates: X <br /> <br />Township <br /> <br />Range Section <br /> <br />WORK TO BE PERFORMED <br />/JEW WELL / BORING ( CPT. GEOPROBE, HYDROPUNCH. HAND-AUGER. OTHER-) <br />SOIL BORING # <br />O WELL # <br />'Other: <br />COMMENTS: <br />9 DESTRUCTION (choose type below) <br />9 OVER-BORE <br />9 PRESSURE GROUT /,-- <br />\P <br />COMMENTS: r.)v--,;-7075 effrt,44 7.15"sr- e-n <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS! <br />: hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Orainances, State Laws, and Rules <br />and Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: "I certify that in the performance of the work <br />for which this permit is issued, I shall not employ persons subject to WORKMAN'S COMPENSATION Laws of California." Contractors hiring or sub- <br />contracting signature certifies the following: "1 certify that in the performance of the work for wnicn this permit is issued. I snail employ persons subject to - <br />WORKMAN'S COMPENSATION Laws of California.' <br />THE APPLICANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />04A?) <br />SEE SITE MAP IN UNIT IV WORK PLAN. DATED <br />DEPARTMENT USE ONLY <br />Date Issued <br />Date <br />COMMENTS / CONDITIONS: <br />AC# <br />• „--......._ .. <br />PE CODES 1 FEE INFO AMOUNT REMITTED CHECKWCASH RECEIVED BY DATE PERMIT/SERVICE REQUE . UMBER INVOICE <br />35-o (;.<69.00 1 1 11 z-- <br />1 it ..•O... I 3 1 1 <br />UNIT IV - 5/99 /MI <br />Signed x u Title 6,514(7\7'j <br /> Date <br />Application Accepted By AA.A.r i>"•*-1 <br /> <br />1 I 1 C) 0 <br />3. [ OP 4- 2-• tr&Final Inspection By Grout Inspection By_LTAAAAc._..cA.,••• <br />Destruction Inspection By <br />Area <br />Date