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SDT BY 9163622318-Sacra. , CA 12-13-99 : 2 16P11 ;RADIAN ISTERSATIONAL- »16/18 <br /> .c �, a�o c.arr, rn�ri � • , � <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBUC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS•EHD) <br /> 304 E.Weber, Third Floor, Stockton, CA., 95202 <br /> (209)488x449 <br /> NON-RMMDASLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County lot a panne to ronsV=andfor bhhM the work cheated. This epplicaoon is rnade In compliance with <br /> San Joaquin County DawlopMrd Tft Chapter Fit 16.3 and the SwWa/rt#of San Joaquin County Pubic Health S"c«,Envkonmentsl Heath Division. <br /> WELL Locatloln I, PoT _Croat su«: L-/y�/' h iy Zip C15-474 <br /> PaReM a <br /> PROPERTY Ow, r�rT �a «a CN'-j4v1rj$. city -r4cxz44y"37('%,onaa <br /> ear conbawor G'r . �i AdTrdrsa, 9� 1 h W cry "�'(t zn�S�/�u�uF'��Pnpnar guy 3/3 ;w <br /> Comulfatisubconbaaor A!kZ hr✓ -1111'/ Addreaa 030 ^ /1 CltysrOL1 4A>Y'RL�tee Phones P4"N _S33z <br /> 03 Coordinate:X .20Q^JS`7DIr`( .Y �e.�Z ` Township rt S Range s.cbon 3 <br /> 0 NEW WELL 1 BORING(CPT,GEOPROBE.HYDROPUNCH,KAND-AUGER,OTHER-) MUCTION(moose type bebw) <br /> 0 SOIL BORWNO Y .13 OVER-BORE <br /> •Otrw: /LF2 WEclt _ S 7 A -rJt,D �]n\'Pa_ESSURE GROUT <br /> C011LIENTS .p/ uYY1 1N as r 8 E Z.O ` u10!Je7D3, A dC11 <br /> TYPE OF WELL INSTALLATION TYPE C RVGTICN SPEGIFICATIO d f*-4,7rk,6- (S !r <br /> 0 MOf11TORING 0 HOLLOW STEM DN.OF BOREHOLE _MULTIPLE CASINGS?n`Y/ES ONO WELLCASINO DIA <br /> 6 <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TY�E OF CASING.')(STEEL '/y$VC BOTHER- � <br /> O VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL .43 TREMIE TYPE TO BE U ES 0 0 AUGERS OHOSE <br /> 0 AIR SPARGE 0 P118H POINT GROUT SEAL PUMPED 0 Y« 0 rjo (NOTE:MAXIMUMFREE-FALLDEPTH 16 30') <br /> O SOIL SOMNG 0 HAND AUl3ER APPROX.BORING DEPTH_& FA TFOIVOX or 0 STOVE PIPE <br /> yLUTHER a,JOTHER SQA"' CONDUCTOR CASING PROPOSED? (r YES.list pacMcationa tare). <br /> s (cel( CA*s r4' <br /> COMMENTS: US 0 b0g• Jre ✓ ; a 46) a Z <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCR ACHMENT PERMITS <br /> I hereby ca.*that I have prepared this application and that the work will bo done In aawdsnce with San Joaquin County Ordinances,State Lewa,and Rulas <br /> and Requadona oft"San Joaquin County. Homeowner or I onneed 2Wz algiUlun oaRBhs the fotiowing. "1 cwrtlfy"In the PvfQwwC$cf Bre work <br /> for wwoh"a parmhh haul,(•ball not emplorpersons aub/act to WORKERS'COIUPENSA TM Lawn of California." Conti agw'c hlrinp m nub. <br /> mrelaet�q sgreture ggrftv SIO Idbwinq:T certMy Me!!n fit per/brmerrps o/(th work for witch this permR h lulletl.f OW employ laagone JuD/ecf In <br /> wOR#CERS CO TION Lswa o(Ceahr <br /> I <br /> Is ons -Z )3 -� <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED: <br /> 11 t, '1 DBPAWNe"Y USE ONLY <br /> AppkaWn Accepled By F k"v)k Doe Issued i13100 I Qj oxj <br /> Grw Inspection BY Oafs Final Inopeepon By Doh <br /> Datructbn In ion By it <br /> COMMENTS/CONtII OW: i�J O-^, � /GJC?.'�. Il✓0�' /.t1)"4.. - LI_.ecetft ESL(. <br /> ACCOUNTINGONLY: AIDS '7 <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKS RECD BY DATE PERMIT I SERVICE REQUEST/ INVOICE <br /> 390 >— 6n <br /> bo- <br /> VW <br /> VW LV-61Z3199/zip bkWMI .. <br />