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SENT BY 9163622318-Sacra. . CA :12-13-99 : 2 16PNI :RADIAN INTERNATIONAL- »16/18 <br /> .a ,o Isom �s:.�.�n rn�r • • . c <br /> w <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 /> (209)48843449 <br /> NON4WVNDABIE P[RMIT EVIRES 1 YEAR FROM DATE ISSUED <br /> Application Is!hereby meds to San Joaquin County for a psmut to construct andlor Install the work duCrIlM, This appicapon IS made In complanee with <br /> San Jomqus County Do ovitaTMnt This,Chapter 9.1116.3 and the Standards of San Joaquin County Public Hamlin Sarvlwa,EnvNwanerdel Health Dwiswn. <br /> �1,,�1- � 4 Aaaesaori <br /> WELL LocaUm Po7` Cross Suer Cye/ "T�rp9� Parer <br /> cPROPERTY <br /> aoow<ns< t�fY a�dreas 9� N Ci1c2ity cnr�4t` (�z'a9 �/Paeanigen <br /> -� -3/3 5W <br /> Cmmutma/Sub Contractor KA-I;thei <br /> Add! at. /V. City- 17fw Pnon.a ��O'' `Z"5332. <br /> 018 Coordinate:X wZC���q'4 Y c.30 Z Township Ranee Saw., 3 <br /> WMTQ BE PFRFORdEO ._ //' __.. ._ <br /> p NEW WELL 1 BORING(CPT,GEOPROBE.HYDROPUNGH,tNNO-AUGER,OTHER') / _-ADESTRUCTION(choose type bei <br /> O BOIL BORINI ,p OVERBORE <br /> •ouwr: /LQ� �u s �t'D SSURE GROUT <br /> COMMENTS .pf nYY1 N .O 1 E 2.O ' Ai-10 '7�y rw 63Q;)Gf , <br /> PE OF WELL INSTALLATION PE C MICTION PMPIG-A eI £p�,yV(-Ate MS I it <br /> 0 MONITORING 0 HOLLOW STEM DA.OF BOREHOLE MULTIPLE CASINGS? YES 0 NO``�''WELL CASING DIA e° <br /> 0 DETRACTION 0 AIR HAMMERIORIVEN CASING THICKNESS tr TYjE OF CASING:�STEEL�VC 0 OTHER' <br /> 9 VAPOR B MUD ROTARY DEPTH OF GROUT SEAL_j' <br /> TRPJd1E rii>E TO BE EO DAUGERS ONOSE <br /> 0 AIR SPAROE 13 PUSH POINT GROUT SEAL PUMPED: BY" p 7o (NOI MAXIMUU9Mtt�AF11((RLFE-FALL DEPTH 1830') <br /> 12 301L BORING y{" 0 hVdID AUGER APPROX.BORING DEPTH__jQ 'BOLTED TFOIFF(GVOX w 0 STOVE PIPE <br /> ER/N}Ft(oa1�THER S494P- CONDUCTOR CASING PROPOSED? (11 YES.IM spadllcagar hare): <br /> s (ugf! C rPee v <br /> COMMENTS: OR.` s /G' ✓'&i b W O GIP AA` . <br /> 7 r cls a cue /z S at <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCR ACH-- PERAAI S <br /> I hereby certify that I hive preparedthis application and that ted work will be done In sorardanu with San Joaquin County Ordinance,Stain Lowe.and Rules <br /> and Reguistions of the San Josquin County. Momewirmr of iossmad aWs slgngsfm oaglflas the following: "1 eertlry that In tMPwfamxra q/tM work <br /> for whlah 86a pa nnifla hauad,l slidil not employ,parsons sualecl to WORKERS'COMAENSA TION Laws of Callfwnla." Contractors hiring or sup <br /> coribactmil slyrelure rtilin Bre following:'I wrtlly Mat in lha parformsxv of Pro wwk for which Pas petmR Is ismor.1 shall amploy Narcan 410W to <br /> WORKERS Cabm <br /> _O TtON Laws of caftan <br /> Soled 7dN / r Date <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED: <br /> �1`I w�� DEPARTMENT USE ONLY 3 10o �1d LYX' <br /> Application Aacepled By i� Dara to <br /> Grout Inspection By. Dain Final inspection By Dow <br /> DabuGion Inspection flyWk <br /> COMMENTS I CON13MOM: i� 0 p, F /LJC:?,1,, J L✓rn C i O.r-t-f��'1^- � ...�+-tG-s �i1-t�:) <br /> ACCOUNTING ONLY: AIDS PAM <br /> PE COOPS FEE INFO AMOUNT REINITTED CHECK• REC-D BY DAT! ►ERIMT I SFJTVICE REQUEST P INVOICE <br /> a9C60 D 7iz� hug l 3 �'✓ pDv SC-• <br />