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10/03/2001 10 23 2094683433 FIFTH FLOOR PAGE 04 <br /> WELL PERMIT APPLICATION FORM <br /> UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION ("PHS-EI-11)") <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3450 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 1,pprrcaton,s hereby made to San Joaquin County for a perPrut to constrict and/or install"*work described This apptrcat,ort 4S msde'n CorOPl'anc-e with <br /> 9-11Is 3 and the Stand of San Jcagwn County Public►4palttt Ser"'cos,Env'roonns� fs eatkh <br /> ;an Joaquin County De-eiopment Title Chapter D'uswn <br /> City 5'ItvC.k� Zip ParctMt <br /> NELLLor-atlon 4315 <br /> t r,4. !^100 1_6 CrossSateet_ <br /> p Cy $,.�rb�� z,sa 915a Pnoneit CS��d45-A3t� <br /> PROPERTY Owner u�1tM r15e.5 Address O DUx �I g�0 7 Cx7 <br /> -�I t sldress D DINL 3l3-SEdo <br /> G57 contractor 'Ta'4 933'2368 <br /> Consultant I Sub Contractor m �Z_ � Vnv1* "A,tdMSS <br /> 2"IO �e►'k:r+s S�- City„ So'r►a�rvta L'c* Pnone� � ) <br /> Township Range Section <br /> GIS Coprdrnates X. Yw <br /> WORK To BE PERFORMED <br /> Ll DESTRUCTION(choose type below) <br /> W WELL I BORING (CPT GEOPROtSE HYDROPUNCH HAND-AUGER OTHER-) a OVER_80RE <br /> LBtOtL BORING# C T- Q PRESSURE GROUT <br /> �' ELL NI 3 cMw-4 m _3 Mw' <br /> Otter <br /> CCSMMEN7S <br /> OF WELL CONSTRUCTION TYPE CONSTRUC'TtdN 6PEC+F1CATtoNS ' YES O WEU.CASING QUl <br /> OLLOW STSM 6� DIA,OF BOREHOLEJ� _12- MtNL7lPLE GASlNGS O 1 <br /> tTORtNG 3 ^I�ryrl:�F GASING 1 STEEL y�/pVC (�OTHER <br /> EXTRACTION d AIR NAMMERJDRIVEN cAsiNG THICKNE55 � F40SE <br /> VAPOR MUD ROTARY DEPTH OF GROUT SEAL. "' SOS T]�EMFE<TYF£'TO Se USeo G AUGERS Q <br /> {j AIR SPARGE GUSH POINT 1 GROUT SEAT.PUMPED d fes a No (NOTE MAXIMUM FREE-FALL DEPTH IS 301 <br /> Olt BORING Cl [) HANO AUGER APPROX BORING DEP t H D 1 Nn tUfB ti s RAF£C BOh or) STOVE PIP£ <br /> \Rt3 DT>�ER <br /> CONDUCTOR CASING PROPOSED <br /> ere <br /> COmmENTS <br /> NOTE. OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS! <br /> be dome Lon s.and Rules <br /> 1 hereby cerufy that t have prepared In,s ap,uHo omen®�ortG�ru ager s s'gnature�cert►i5es the forda ra kq.nJo 9l carr fy th Out die perfdnmaacs of the work <br /> and Regulations of the San Joaquin CountyRXmAWS Of <br /> for which this permit rs;f svaQ 3jall no'T certify flrat'n tha perfbrmance of the war*fnroy peysons subject to WOOwhich'"pamrjt IS rS usd.I shat omploy po anS subject Po_r4DmJ3' Canuactors hiring or Sub- <br /> contracting _,gnature cert 'n9 <br /> y oRKMAN'S CCmP61VSATIC1v Caws of Catrlomra " <br /> THE APPUC NT MUST CALL 48 NRS IN ADVANCE FOR A rLL.�REQUIRED WSLLPECTIONrS� O [ <br /> Signed x <br /> T',tle_Lr� �^ t°IST Dat01 <br /> e <br /> SEE SITE MAP N UNIT IV WORK PLAN DATED S~ b <br /> PQ TMENT SE ONLY <br /> tssued <br /> ate..... <br /> Appl,cat'on Accepted B Final Inspection By Oxte_� <br /> Grout Inspection Date gy <br /> Desvucttor%In-5004=10n By Date <br /> ComMENTS/COPIDITIONS <br /> FACS <br /> AGCOUNTING ONLY AID* <br /> Pfi CHECKIR1CASi! C f] <br /> D TE f'F-FtL tTISERVICE REQUES-r NUMB Eft INVOICE <br /> CODES FEE INFO AMOUNT REM11TED <br />