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08/23/99 RON I8:51 FAX 51.0 653 0350 GEONATRIX OAKLAND lit004 <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHO) <br /> 304 E.Weber, Third Floor, Stockton, CA.. 95202 <br /> (209T468-3449 <br /> NON-REFUNOAB PERMIT EXPIRES t Y AR FROM DATE ISSUED <br /> vro <br /> San Joaqu n ountymade Deve moment T'nle,San uin County Chaptar 9-i 15 3ermit to construct and the Standardseofley Sa'n Joaquin County Public Health Services, EnvCiiltmn is ironmental Hade In ealth Division. <br /> San Joaquin County lap Assessor's <br /> WELL Location <br /> Cross streetFlCdpy,-�'�L—rl-- ZpL�p9S'S7bPPahracneel*s 2h5tA4 <br /> -n -07 <br /> PROPERTY Owner I11 ,5M IS Aie]B >s <br /> Address 7F7A� 5. ^Yi< n'GM�Y --n—,,I,— <br /> ILII 6 f-;6i1. ry'ltrt[.�" city _ZI Liete4 5T Pnonell SlO Z?S7-k5'r5 <br /> C-s7 Cortlrador Peaei�+m__ �ay.�Addrass �L& <br /> J Address SwI W'tbS�'f+l' I? ? IMA "_4_UcilNl Phoneit'2d"�n3-4273 <br /> Consultant Sub Contractor �+gym nom— t" <br /> ,Township Ran9a Section <br /> G15 Coordinates:X �� /I:ZL-- Y-- <br /> WORK TO BE PERFORMEp <br /> II DESTRlyCT10N(cheese type below) <br /> j N <br /> - EW WELL I BORING(CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER-) Q OVER-BORE <br /> SOIL BORING* - �' 17 PRESSURE GROUT <br /> 1 WELL R <br /> -Other: <br /> COMMENTS'. <br /> TYPE OF 9-LI.: -INSTALLATION TYPE CONSTRUCTION SPECWICATIONS <br /> DIA,OF BOREHOLE..._MULTIPLE CASINGS,OYES n10 WELL CASING DIA: AA <br /> Q MONITORING 6 HOLLOW STEM <br /> II EXTRACTION AIR HAMMERA7RiVEN CASING THICKNESS NA TYPE t�EC'SEI�E TD BE USED,.p AUGER6R. �F�IOSE <br /> fl VAPOR a MUD ROTARY DEPTH OF GROUT SEAL N -- <br /> U AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes )po tNOTF.MAXIMUM FREE-FALL DEPTH IS 30') <br /> ' AIR BORING Q HAND AUGER APPROX.BORING DEPTH_ c Srii- u BOLTED TRAFFIC BOX or U STONE PIPE <br /> p OTHER: 0 OTHER CONDUCTOR CASING PROPOSED? t{ft_ (If YES,list speciftetions hare). <br /> COMMENTS: <br /> NOTE; OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> 1 hereby rxA6Y that I have prepared this appiicetlon and that the work will be dime in acwrda as he j San Joaquin County t in fil nt-es,State Laws.and Rule <br /> and hereby <br /> Requistlons f the San Joaquin County. Homaewnar r licensed tants signature <br /> O pFN$ATIO ors ocertify <br /> f Catifori " rA ��Mftiring or sub- <br /> (or which this permit Is issued,I shelf not employ pars for rsana subject to <br /> contracting signature carafies the following'.'I cerfli that in Ne peAonnarice of NOS "'ham lnls permR Is issued,1 shall empty pe <br /> 4WRVCERS'COM,. NSA TION Laws a/Caleramil <br /> THE APP MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> 6-3 <br /> Sgned x Tills,. l' 1, N <br /> YVi <br /> SEE ITE MAP I , UNIT IV WORK PLAN DATED 0, <br /> DEPARTMENT USE ONLY bb <br /> Date Issued nl I tCi Areas J Gr i$ <br /> Application Accepted BY Osla Final InaPer-ton By Daae <br /> Grout Inspection By <br /> Destruction InsperJion BY fate S <br /> COMMENTS I CONDITIONS: <br /> FAOB <br /> ACCOUNTING ONLY: AIDS <br /> PE CODES FEEINFO AMOUNTREMITTED CHE q.y�SyH RECEIVED BY D �t� PERMI^ECUEST NUMBER iNVO <br /> SOI IQ.Y ©f� ilJ O . .. <br /> UNIT IV-6/23!94/sign bkpg/MI - <br />