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08/23/99 MON 16:40 FAX 510 66:1 6550 GEOBATRIX OAKLAND 0002 <br /> - - • )UNIT IV <br /> WELL PERMIT APPLICATION FORM <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION(P,F'4t202 ) <br /> 304 E.Weber, Third Floor, Stockton, CA.;95202 ;• Q 7 <br /> (209p 468-3449 <br /> NON-REFUNDABLE PERMrr EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application b hereby made m San Joaquin County la a permit to construct andtgr install Juin County Health Serlrces, Environmental cawn is made in compliance <br /> Hearth Division. <br /> San Joaquin County Development Title,Chapter 9-1115.3 and the Standards et San Joaquin ty Assessofe <br /> T yy(_Q.d _21pJ 3 (P PaKe1N 1Sz"U T'61 <br /> WELL Loration_S c 04lrf* vs R .,1 Cross Street Eiars"'F�5'I—Cfi T!r[A 7 <br /> -Tr„re�2ip�y„1�,Phonell r�tA <br /> PROPERTY Owner.0•:4- ' 4Fa.ipS of Awr[tih.Address 2�7fID s,ci;,:s.--r _�� a�p,f' U /p3638'7 Phonex�lo 237- 575. <br /> n /j�ddress 100 4 '-ibth +4Q'CR.� CilrYllGl6sn=tan-�pit�— <br /> C3T Contractor Pfa 'sib r }, - <br /> Consultant I Sub Contfadur G�61lrtL\'1if l n <br /> Addrese�61 .VC !>�1CnI'. 6 -LrdF NrA Phanaff5l0'(a63ti22T� <br /> 22 ) 131 O ,Townshlp Range.Section <br /> GIS Coordinates:%�•�Zla u �Yl <br /> WORK TO BE PERFORMED <br /> 0 OESTRUCTK)N ichoox type below) <br /> NEW WELL 1 BORING(CPT,GEOPROBE.HYDRO PUNCH. HANO,IUIGER,OTHER') U OVER-BORE <br /> )CCSOIL BORING 0 R 1 —R-4 — Q PRESSURE GROAT <br /> O WELLS <br /> •Direr. <br /> COMMENTS: <br /> TYPEOF WELL INSTALLATION TYPE CONSTRUCTION SPECIryryFIrr1C1ATI MULTIPLE CASINGS?OYES NO WELL CASING DIA'- NA <br /> B MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE PVC 20 <br /> 0 EXTRACTION `<AIR HAMMERIDRNEN CASW5 THICKNESS N A ��yyA TYPE OFR CASING:EMIFYPE TO BE (I Q Al OTHERGERS OH SEo <br /> o VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL y^— <br /> pAIR SPARGE PUSH POINT GROAT SEAL PUMPED: 0 Yes J(No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING B HAND AUGER APPROX.BORING DEPTH IS Tui' 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OIL B. II OTHER CONDUCTOR CASING PROPOSED?_�(If YES,list specMcations here!- <br /> COMM94TS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> and RegulaMona of the .loaqu�ln Countthis y. Homeowner or licensed agencadi-I Old that tie"011;1@111 nt's signature certiefies the WInce Slowingon eQl aeAhy thaOt M th pedfodm n of Ne Rwars <br /> for which this perm(!Is Issued,I shaft not amMQY Parsons subject to WORKERS'COMPENSATION Laws of C�Wsh8ff 6 Oontra Jr3 fi sub ect to h- <br /> contract ng sigruduttt cmQlies the folbwino:Y codify that in the PW*Marwr of the work fod ufirch this pemrit is issued.I shell empty pe 1 <br /> WORKERS'CO is Ti Laws -amla." <br /> THE ON La <br /> T UST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Titlef <br /> Signed x <br /> SEE SITE MAP IN NIT IV WORK PLAN DATED o� <br /> DEPARTMENT USE ONLY <br /> 1�1 Date Issued Ql > 'i Areae Ut2W[7 13 <br /> Application Accepted By FMN Inspection By Data <br /> Grout trtspaction 13 Date <br /> Ceslrucilon Inspection 8y Dale <br /> COMMENTS I CONDITIONS W =� 1 S C <br /> FAC# <br /> ACCDI1NffNGONLY: ATO# <br /> PE CODES FEE INFO ANT REMITTER CHEC C CAS14 R CEIVED BY DATE PERINTISERVICE REDDEST HUMBER INVOI <br /> MOU <br /> �1 71 <br /> UNIT IV-6/231"/sign bkpg/MI <br />