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i <br /> Ll2 <br /> > `" ' M UNIT !V <br /> WELL PERMIT APPLICATION FORM <br /> Q SAN JOAQUIN CGUNTY PUBLIC HEALTH SERVICES <br /> ! t C ENVIRONMENTAL HEALTH DIVISION (PHS-EHC) <br /> :., Ic WI <br /> - j D- 304 E. Weber, Third door, Stockton, CA., 95202 <br /> _.. z (209) 468-3449 <br /> NON•REFUNOABLE PERMIT EXPIRE I YEAR FROM DATE ISSUED I <br /> Appiicaticn is terata{made:C Sa _a3au:^Coe r.,ry sor a cemn t3 canstn:c.Zndlur mstau:h^Ivor~desciteil -his aoolicz!ion s mace it cor,olfanca visa <br /> Sar boa u:n county Oevp!ePment to Cha[+'er S•t i 35.3 and the Standares a!Sar,Jaaau;n County?uhiie -leailn Serry :. Env As $50, oal h Division <br /> W 11th Street Chrisman Rrt� Tracy 95376 parc�tiF N/A <br /> WE_L Location c:nss Sleet <br /> Z=C Phcre4 <br /> PROPERTY Cvrne <br /> ,San JOa tlin Courit ,dans City <br /> Spectrum Exploration 2365 Wi wam Gty6tocls_tori=c_252Q122�� Q°e"���9�MILS- 712 <br /> C-57 Ccntr.Ctgr Addrest— <br /> The San Joaquin Company 8617 Etcheverry pit} Tracy �tcx P�ione�209) 832-2910 <br /> Address <br /> Consultant:Sub Contractor <br /> y .Townsnio_ Range 5errior <br /> GIS Caord.raMs:X <br /> WORT{TO BE PERFORMEC <br /> ,� v HAt4D-ANGER.OTHER') ] DCSTRUCTI 0 [c:zz-8 type ceuwi <br /> �E'/J'NELL!BORING{CPT..�L. RC3E. H.4ROt�UNCH. � o.POP.E <br /> �QIL BORING# QE--SURE GROUT <br /> (a/rvELt rt___ <br /> -Other — <br /> GCMMEyTS: See Attached <br /> TYPE OF YJeLL ,NST. LEATION TYPE CCNSTRUCTION SPECIFICATIONS - <br /> /*'OLLDY7 STEM Dt4.OF aORE`iOLE 6 rt MULTIPLE Cf SINGS r a YES g+IO '!vE_i r�S NG rOlAZrr <br /> F fONITi~FiING tl/ gkA <br /> AIR HAfiMER/DRl'�EN CtiS!NG'HICKN€SS SCh 40 TYPE OF Cf,SI'aG: STEEL u:+VC a CHER: <br /> VAPOR-TION (] r -7REWE,(PE TO BE USF:): 9 AUGERS JS= <br /> Q bAF'Gf2 �'1UQ R07APY DEPTH OF GROUT SEAL 6 <br /> 0 AIR SPARGE -Q1'-I:SH ?OIN7 GROUT SEAL PUMPED: eas 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 21 &4OLTE0 TRA-FF:C BOX or Q:.TOME PIPE <br /> jrls'111! BCRING. O HANG AUGER APPIZCX.BORING OEPT^i --- <br /> DTHER. OTHERR <br /> CON:)LCTOa�SINGPROPOSEn?NO ( °f YES rsisoecifcatior.s ere 1:_ <br /> COMMENTS: See attached Figure 11 <br /> NOTE: OFESi i E BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> tn County State L avrs.ant Rums <br /> rereoy cw-+Y that I halie preparea :his aopiica:ion an::h.:the work w0 pe 90.18 in ace:n3anCe wit"San:oaauOrpinarc_s. <br /> tions of the San Scaquin Coun�v. Horreowrer or i•censed agen"!signature-e!tlfies the-01:Cwi�g' "1 certify that in the perrarmarce of the•verk <br /> and Reoula <br /> sor which this permit is issued. !shall notompfoypersons subject to WORKERS'COMPEN5AT:ON Laws ofCaf7ornia." t-cntraCEO�s SGA"2C^-r+ <br /> ccntrac:inq Signature certiti8s tae °oitawing: "I C9rtily t`af in.' ich�y9 CerfO:77anC&:.f the work orv�hrhu perrnrr i.1issued i shah sm�'cy, <br /> yYORKB'rS'C0.WpE;Jv'A7,CAi_s.vs of California.' <br /> THE APPLICANT MUST CALL 46 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTICNS. . <br /> J %;73I23I40 <br /> TItIa Consultant p41e <br /> .j iLnsd Y <br /> t , <br /> SFE SiITE M{AP IN UNIT IV WORK PLAN DATED: <br /> DEPARTMENT USE ONLY <br /> _Cate '$sued Brea—.= <br /> Appiicat:o^.4CceGtea 5S' — Da*e <br /> Gout InspKtion By <br /> Oatir:al Inspection 9-14 —� <br /> Destruction insoection BY Data <br /> COMMENTS f CONDITIONS: <br /> ACCOIJNTIiV'�j ON!Y: iIC= EACN <br /> a S FEE 1NFJ AMOJNT REMITTED 4 GHEC+C sy k RECD 8Y ' DATE PERIVIt i+SZA'JICc REQUEST A � 7tvLCiCc <br /> --3 - — <br /> C-37 LICENSED CONTR:%.C7'OR MUST SIGN-LICENSE 6twUR-XER-' CON'EVSATION DEC: AxA <br /> TI��ti <br /> UNIT i'r •h/2-ro4 Jstcn bkc:jiML <br />