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SENT BY:9163622318-Sacra. , CA • 4-17- 0 ; 1:35PM ;RADIAN INTERNATIONAL- 2094683433;# 7/ 9 <br /> I G-•1 IT 1`,JrJ`J- <br /> 14:41- M&KUM • P.,Z <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHO) <br /> 804 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209)468-3449 <br /> RMU EXPIRES T YEAR DATE ISSUED <br /> Application is hereby made to San Joaquin County fora perms to construct andlof Inatall the work described. This application is made In MMPllance with <br /> San Joaquin County Development Title,Chapter 0-11163 and the Standards of San Joaquin County Public health Services,Environmental Health Division. <br /> Asse <br /> 11t/ELL Locatlan �n72gcy k4 Crosses rrr)IQWAJ CY"l r'•✓TC�/ 7ip pt 76 P mlasor's �1 <br /> PrtoPeRmOwner°'C s'rSQ. 1�7J�s �S/AddreeariA[gSrye-fN✓1.a3,M-(� 'Cnv-7V•—.'- z1P /S-374phones -K,93Z-'i667-de <br /> G87 Gprarapar Address cay� �r zP uar yf�ll Phwlen t3a-667-e <br /> Comultant/Sub Contrawar l,4Ab%/yfy �Nf(. Addrass. 103/ Y 6to M�Clkry'd rl r"Llar Phones <br /> GIS Coordinates:XN•'w `tSa.b YE.63D3bb Z-�- Township 'Z� Range rSection 35- <br /> WORK <br /> SWORK TO BE PERFORMED - <br /> 0 NEW WELL I BORING(CPT,GEOPROBE•HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type bebw) <br /> D SOIL BORING 0 0 OVER-BORE <br /> r7v <br /> W-It* �PRESSURE GROUT <br /> *Dow : &WAFLTJ�dw Gca 0 4�'c a yr c �FAAWP O)ve5 <br /> COMMENTS: '�-'--- <br /> TYPE OF WELL INISTALLA110H TYPE CONSTRUCTION SPECIFICATION3i, <br /> 0 MONITORING Q HOLLOW STEM DtA,OF BOREHOLE X MULTIPLE cAswm O YES*0 WELL CASING DIA: <br /> ? X'TRACTION 0 AIR HAMMEWDRIVEN CASING THICKNESS TYPE OF CASINGD STEEL *VC Q OTHER: <br /> Q VAPOR -11U0 ROTARY DEPTH OF GROUT SEAL D- TREMIE TYPE TO BE JSED: D AUGERS OHOSE <br /> O AIR SPARGE O PUSH POINT GROAT SEAL PUMPED: '))�(es O No (NOTE: MAXIMUM FREE-FALL DEPTH IS 3o') <br /> D SOIL BORING D HAND AUGER APPROX.BORING DEPTH �, 0 BOLTED TRAFFIC BOX or*70VE PIPE <br /> D OTHER: 0 OTHER CONDUCTOR CASING PROPOSED?_ ( f YES,IM aped6oationa hate)' <br /> COMMENTS: K&#4 A, „Q, r <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby certify put I have prepared this application and that the work wi one n accordance with San Joaquin CWnty Ord rarnxa,State Laws,.4 Rules <br /> and Reputations of the San Joaquin County. Homeowner or licensed agont's signature certifies the following: '7 cupry 0Wf In the perforansnce of the work <br /> for which Phis permlt/s Issued,I shell not employ persona subject to WORKERS'COUPENSATION Laws of California." Conbaetor`s hiring or sub• <br /> contracting signature certlSes the following:Y cvilify that In lis Perrormerve of file cork for which this permit is Issued,I shalt omproy par=S.Vokoct to <br /> WORKIRS'ICaOMP�gE�NS�AYTIION LaaaMgmof Cakibaw, <br /> _ <br /> F _ _,. ��S�filL�r��k11��!layll, .l 9Kllkll{a���.. s7AA4PE18 <br /> Spnad ° � T111e �/�� lista 3 D() <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED: <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Issued <br /> Aroa <br /> tlmd Inapadion BY bas Final Inspection By Date <br /> Destruction Inspection Sy Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ON LY: Altus <br /> PE CODES FEE fNFO AMOUNT REMITTED CHECKO RECD BY DATE PERMIT SERVICE REQUEST 0 INVOICE <br /> UNrT IV-6J23/99 lingn bkpg/MI _. _ •� — t_ <br />