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Q0 <br />WELL PERMIT APPLICATION FORM <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 />UNIT IV <br />NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br />Applicatcn is hereby made :c San _oaou,^ Courry for a permit to Construct and/or install th5 %vorK descriced -his aculicatirn s mace to cor-aPanca •r:tn <br />San Joaqu*n County Davolopmenc 71,,te Chapter S-1115.3 and the StalaarCs of Sar ..oaeuin County Public Health Servt�es, Ern• ronr .ental H=al:h Division <br />Assessor � 50150-18 <br />WE_LLo�ation 7500 W 11th Street CrossStreeiC:hrisman Rt/� r3z 2:0 95376 Parcel# <br />Carl & Annamae Navarra 475 W Blewett c; racy zio95376 Phcrex(209) 836-0005 <br />PROPERTY Owner address <br />Spectrum Exploration 2365Wi wam cit�Etockton=p95205'_:12268Ph'^eZ92�46��712 <br />C-57 Ccntrctor Address g <br />The San Joaquin Company 8617 8617 Etcheverry-;y Tracy L! C,7 Phonea(209) 832-2910 <br />Consultant; Sub Contractor <br />GIS C::ord.natas: X • Y . Townshio Range Sectior <br />WORK TO BE PERFORMEC <br />*JEW WELL/ BORING (CPT EC-RCBE, HYDROPUNCH, HAND -AUGER, OTHER-) <br />Iij�S BORING # <br />VWELL *--- <br />'Other: <br />COMMEVTS. ee Attached <br />.1 DESTRUCTION (choose type <br />0 VER-20P.E <br />�'oE=SURE GROUT <br />_ _ CONSTRUCTION SPECIFICATIONS / ')IV `/ <br />&40NITORING '{DIOL LOVY STEM DI.A. OF BOREHOLE 6tt MULTIPLE CASINGS, 0 YES 1 NO tiE_ CASING DIA, <br />Q EXTRACTION 0 AIR MAMMER/DRI'JEN CAS!NG THICKNESS <br />SCh 40 TYPE OF CASING: Q STEEL >DAVC S CTH_R: <br />Q VAPOR a MUD ROTAFY DEPTH OF GROUT SEAL 6 r -REMIE TYPE TO BE USED: 0 AUGERS 1�f(JSc <br />a AIR SPARGE VLSH POINT GROUT SEAL PUMPED: V'Yes g No INOTE: MAXIMUM FREE -FALL DE?TH IS 30') <br />U/SGL BORING. a HAND AUGER APPRCX. BORING DEPT -,1 21' LTED T RA.FFiC BOX or 0 -STOVEPIPE <br />/ <br />p OTHER. CTHER CONDUCTOR CASING PROPOSED? NO ('rYES I st soecifcatior.s ere):_ _. T- <br />COIYMENTS: See attached Figure 11 <br />MC)TE- OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br />C'q <br />I hereby certify ;hat I have preParea this aopucatien ane that the work wH be cone in acc: rdance vv:t'^ San Joaeuln County Orairances, State Laws, an:: rocas <br />and Regulations of the San Jcaaun County. Homeowner or i:censed age.• s signature Cert!fies ;he 1ol;ewing' " t Certltj! that to the performance o/ the Werk <br />hirng of <br />for which this permit is issued. .1 shall not employ persons subject to WORKERS' COMPENSATION Laws of CJ1MdMi3." '�antraCto'S <br />ccniracting signature certifies trie Viowing: "t certify t''at in ;h9 oerfornance o.• the .vork'ors.hich this permit i; issued. I shall grro-o'cy persons subrec- rQ <br />WORKERS' COMPE;V�,ATiCN _.aws of California.' <br />THE APPLICANT MUST CALL 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSpEr.T{GNS. <br />�• �} Title (c,tis� D .e 3/23/00 <br />Signed x <br />SEE SITE MAP IN UNIT IV WORK PLAN DATED: <br />DEPARTMENT USE ONLY zno <br />Appticat:or Accecteo By—� __ -Cate 'ssued_ Area_. <br />G out Inspection By <br />AAA r^C — Date '-I Z.' -a 0C.Anal Inspection By Date--- <br />COMMENTS <br />ate_— <br />COMMENTS I CONDITIONS: <br />ACCOUNTING ONLY: AICA _ <br />°E ODES FEE INFO AMOUNT REMITTED �I CHECK ay RECD BY ; DATE PERMIT <br />qj Sp# Dd 22-- Sb <br />G57 LIC-ZI14SED CONTILkCTOR MUST SIGN LICENSE 3iWC;& S S-r�I'L�I�-15F <br />UNI /stcn bkogiML <br />x I ;NVCICE <br />LA 1 !LTIL: <br />