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Sep 27 04 04: 23p Avalon Environmental 714P^56642 p. 4 <br /> )-l d-1999 9=50Af 1 FRQh1 <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION ("PHS-EHD") D <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3450 <br /> NON-R .7UNO!>Bt_£PERn EXPIR`S I YEAR FROM OATS ISSUED <br /> Apolication is hereby nude to San Joaquin County for a Permit to qI ant'Jor,nst2It the work desvibed. '(Kris applicat+on is nude in xrnofiance with <br /> n!Ttla.Charier 9.t i Y5.3 and tike$tandands of San Joaquin Courry►"ruDi c Health Services.EnvhronmenL3l Heath Division. <br /> sari Joaquin County Developrne AsSEsso(s <br /> r <br /> Cross 5veet, ,�Q_ (I�cn, �1 : ± City S�PD[��zi0 aaroeto <br /> WELL LoItid, I 2 2 ! Dri�e1ecl - <br /> Cit, <br /> PROPERTY OwnerAddress,t X87-?Uph kAf__w�Oxt <br /> _Zip�j Ianonefe <br /> 14i"-WI�--�' CttY ko V I Jac. Pnone ����7Sf-Z 8!S <br /> -57 CpntaCtor C��%'s.-(Z-QO�-Aad ens nU•J I <br /> Consur-ant f Sub Corruactor dr <br /> Adess Pnone=,,.7Yg-AY(L X69 b <br /> GIS Coordinates:X Y <br /> Township R7riiz StG:O'h <br /> WORK 70 8E PERFORMED <br /> Ti <br /> Q Q YDROJrC . iANO AUGEr.OTHER') B � DESTaUCTCIOQN(choose type <br /> below) <br /> NEIII f BORING(CPT,GEOPROBE VER-BORE <br /> PRESSURE GFOJT <br /> SOIL BORIN C 'I <br /> Q WELL= /L«� <br /> ,other. <br /> :OMMENTS: <br /> lfp CONSTRUCTION TYPE CONS'�RUGTION SpEC1FICs.=(ONS 7 YES Q NO WCL_CASING DIA: <br /> DtA OF 30R=Hat MULTIPLF-Ca52NG5. Q <br /> �iAONRORING Q Ho - Sri TYPE OF CASING: US—,EEL Q PVC Q OTHER: <br /> J(TR/tGT10N 0 AIR.(AMMER/ORIVEN CASING THIGKNEu`.---- <br /> DErTI H OF GROtT SEv —__� {E TYPE TO 3=USED a AUGErZS pHCs� <br /> `VAPOR Q Muo ROTARY Yes (NOTE.NOTE. MAXIMUM FREE-FALLDEPTH IS 30') <br /> a AJR SPARGE Q PUSH POINT GROL<SES QU EO: Q SOL�fl FIC BOX or 43 STOVE PIPE <br /> Q SOIL 13ORING Q RAND AUGER APPROX.50RING DEf�Trr (I <br /> CONOVCiOR CASING PROPOSc07 ( YES-fist specrCcalwns brie): <br /> n'JTHcR <br /> COnAMENTS: <br /> NOTE: OFFSITE BORINGS1 3R�EQiqt UIRE AGeCES-�A Ce with ENCROACHMENT ordPERMITS! <br /> �cRas Sta Slaws.ana^"les <br /> neretry GCr✓tI'trtar 1 ha•c prem red tr++3 apP eni•S z naturr Cerfifit3 the tdttowing:'I Certify thif in Me perfor+Thdn Ce of the work <br /> ersOr 4 subject a yyORKMAH$COMpENSAMN Laws of Callfomis." Contrar:tor's hinrtg Of W%>- <br /> and Regul;=Ona Of the San Joaquin f3a[l nCounty. Nw pet or licensed t gr Kis issveQ f srraff lMPJOY persons sul%iw-to <br /> .a which avis permit is issued.1 anal!not NttD1oY p of m#work for+"roar Otis Pw= <br /> ;ontnct;np Si9naturC Ce e t ng:7 Gertlfy ilial in tho perfomnanCg <br /> ws ar AEQUIRED INSPECTION <br /> NCJpKMANSCO -NST10ty <br /> E FpnLtCA 3T CAL' 48 HRS IN RQVr'1thC�FQK ALi R <br /> r o"Q Daterew <br /> 9 <br /> Signed <br /> t�Eu42 �N�oGN.Z <br /> SE SITE MAP IN UNIT IV WORK PLAN- DATED <br /> DEPARTMENT USE ONLY <br /> d <br /> 0=Issued <br /> Aoglication Accepted BYOate - / First tnSOACbOn By <br /> Grout Inspection 8Y <br /> Dare l 2 q pqy <br /> pestrucsron lnroection By <br /> COMMENTS f CONDITIONS: <br /> FACS <br /> ACCOUNTING ONLYAIDfl <br /> CHECKsfCASH RECEIVED BY DATE PERHtiTlSE3iY10E REQUEST NUMBERfNVOIC= <br /> PE CODES FEE INFO AMOUNT REMlTTEO 10 <br /> O 2/ <br />