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09/15/99 WEI) 13:37 FAX 510 663 6350 GEORATRIX 0ARLAND 002 <br /> rT�t— — <br /> hwLL PERMIT APPLICATIOT& 611v <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERX1� I�S1 1999 <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) 'ALTH <br /> 304 E. Weber,Third Floor, Stockton, CLAN\90021,viEN <br /> T / SER'�IWTII <br /> {209y468-3"9 PERW <br /> MON-REFUNCA15LE PERMIT EXPIRES I YEAR FROM PATE ISSUED <br /> Applic2tion is hereby made to San­102CIUin County for 2 Permit to construct and1w instaif the work described. This appiic2ticil is made in compliance with <br /> San Joaquin County Deve:oprnQrit Title,Chap-at 9-1115.3 and the Standards of San Joaquin County PutAc Vieaft Services,Environmental}Acafth Division. <br /> Assessors <br /> WELL Location Crass strect. (prr,[ kDtA)_City *e-CA zip t&3-7t, Parcew_2&d1f_)_v_f <br /> PROPERTYOwmer Pomba -bi Add.. 122JW, If+- h 5&"+ _City <br /> C-w contmcftafrfri5"�owTess 444- <br /> City A 1-dAw'%04zjP Lia#4M b2 Phonelt—VP -7 <br /> t"117 <br /> COnsulUntiSub Contractor __^mressZL0LLxv!2c,"x-W"A. cty <br /> Township_Range Sedion <br /> WORK TO BE PERFORMED <br /> WELL I BORING C CPT,GEOPROSE,HYDROPUNCH,IHAND-AUGEP,OTHER-) 12 OESTRUCTIOu(choose type below) <br /> ASOIL 13ORING a OVER-BORE <br /> 'Othar: 12 WELL 0 [1 PRESSURE GROUT <br /> COMMENTS: <br /> TYPF,OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 12 HOLLOW STEM DIA.OF 8OREHOLE__NA MULTIPLE CASINGS?B YES 17 No WELL CASING DPA-_,NL <br /> a EXTRACTION 1]AIR HAW4ERMRIVEN CASING THICKNESS NA TYPE OF CASING: (I STEEL apvc aoTHER.. MA <br /> OVAPOR aMUD ROTARY DEPTH OF GROUT SEAL NA .TRE11AIE TYPE TO BE USED: 11 AUGERS WOSE <br /> 1]AIR SPARGE APUSH POINT GROUT SEAL PUMPED: [I Yes %[No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> -*SOIL BORING 13 HAND AUGER APPROX.BORING D I etc 13 BOLTED TRAFFIC BOX or 11 STOVE PIPE <br /> Q OTHER: I]OTHER CONDUCTOR CASING PROPOSED? NA' (11 YES,Vgtt sPecift0ons here): <br /> COMMENTS.-f-10 <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby certify that I have prepared this application and that the vv*wffi be dam in accordance with 361n Joaquin COMItY ONimilincas,Stale Laws,and Rules <br /> and Regulations of the Son Jo2quIn County, Homeowner or fleensed agent's signature cartises the FdIWMng: "I cettW that in JAa psrrormamm Oros*V,*,k <br /> far which this permit Is ftsusA)shall,tot dffl*0yP&nwnj1 subject to WORXERS'COMPENSATION Laws of Wforwa," Contractor's hiring orsubr <br /> contracting 5"tury card&*Jh*kNowirw, ?offr*vweAl the penbrmwwe offho work for whkh thts pwmk Is Issued,I shall snrpmons SL*;Vd to <br /> MRKEJ" SAWOAt Laws ce CaMbMAL <br /> THE A PA" MUST CALL 48 HRS IN ADVANCE, <br /> DVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed x Date 49/i <br /> SEE SITE -MAP I UNIT IV WORK PLAN DATED <br /> ApOcatiori DEPARTMENT USE OINLY Issued__ A a <br /> 'Date <br /> Grout laxpfthcrr By -Date Final Inspection By _Date <br /> Destruction Inspection By Date <br /> C13UMENTS I coNanoms.. <br /> 1E <br /> THE I <br /> x ZL _ <br /> E SITE <br /> ACCOUNTING ONLY: Alov FAC* <br /> "NG <br /> E; <br /> PE CODES FEIE INFO AMOUNT REMITTED CHECKJMCASH RECENM BY DATE PER&UTISFRVICE REQUEST NUMWA INVOICE <br /> §R# <br /> lam= <br /> U__Mmwm <br /> UNr'r ry-6/23/99/sign bkp9/M1 <br />