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t <br /> -U �a 1 <br /> o = U <br /> .. 7 <br /> z (1 WELL PERMIT APPLICATION FORM UNIT IV <br /> LO -- <br /> Or- Sr <br /> SAN JOAQUIN CaUNTY PUBLIC HEALTH SERV!CES <br /> Ul ENVIRONMENTAL HEALTH DIVISION (PHS-EHO) <br /> Cr CL 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> Z (209) 468-3449 <br /> NON-REFUNDABLE PERM17 EXPIRE5? YEAR FROM DATE ISSUED <br /> Apoicaticn is ner.!by made co San _Squirt County Ior a Perrin to construe,analor install;he wor..descrier t -his aAOlire!rprr'S mdc-rr cor7l+anca Ha.`. <br /> San Jaaqu n%minty Devolopmenc a Chaptat s-1 115.3 and the Stanaares of Sar.,toaaucn Co inty 'jb:ic Health Service:;, Er,v ronnental heal:h Division <br /> t o w 11th Street Chrisman RNavarra c}� Tracy Z:CA pare l"';�S 0/�d' 17 <br /> WE'_L Location�^� q -:::ss S.reet ttY_ <br /> PROPERTY Owner Carl & Annamae :r:Gr? s 475 W Blemw2l -EL_.0+tvsrar4i: —zior.A _Phcne#( - 05 <br /> Exploration 2365 wigwam Ci1j,Stockton -;� 95205512268Ph.,r,I-(209) 465-8712 <br /> C-S7 Canu--ctor Spectrum Address - <br /> Consultant:sub Contr,ttoThe San Joaquin Co-Adds,, 8617 Etch!j err —L°cam Pho^ 10 <br /> GIS C:.ord.nates:X Y Townsnio Range SecrlCr <br /> WORK TO BE EO <br /> PE=RFORMED <br /> �>=/JWELL r BORING{CPT. �ftCBE. HYDROAUNCH,H.1ND-AUGER.OTHER-) DESTRUCTION �_ho�se type zeiaw) I <br /> IfSO1L BORING# p CVESSURE <br /> IQs==suer GROUT <br /> 'other: bee FE-a cli R& <br /> CCAAKAENTS: 1. <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS `� <br /> ONITORIMC, VOLLCrV.[STEM DUO.OF BOREHOLE MULTIPLE CASINGS?(]YES ytSNO `hE;_L�S;NG OIA'2�! ,_ <br /> FXTRACTION a AIR�!A-MIMEPJDRIVEN CAwz!NG 7XlCKNESSS Com^TYPE CF CASING: 0 S'+EEL V/PVC Q CTHSR: <br /> Q VAPOR o `1Uv ROTAFY DEPTH OF GROJAL T SS -,-REMIE TYPE TO BE USED: 0 AUGERS IROS- <br /> AIR SPARGE 'e-USrE POINT GPOUT SEAL PUNIPM fes 0 No (NOTE: MAXIMUM FREE-FALL DE?TH IS Ca') <br /> 13 <br /> VSCCiL BORING. a HAND AUGER APPRCX. BORING DEPT-i 21' trfOLTED TRAFF:v BOX or 0 ETOVE PIPE <br /> 0 uTHER. 0 OTHER CONDL;CTOR CASING PROPOSED'> No ( YYES I st soveMc3dors <br /> COMME3T3: See attached Figure 11 <br /> NOTE: OFFSITE 80RINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I rerery car.3y;h&t I have prepared this 2opricalic-1 anc Ira,tine work wi'•I oe cone in aCC_Mance v.'a^ San.oaauin County Clainarcas. S!3te Lavrs. an�P :mss <br /> and Revulations of the San Jcaa, cn Cocn:y. Hcrreowrer or ^_ensed agent's signature to t!fies:he"ol:Cwigg' "r certify that in rhe pertbrmai-ce of rhe wcrk <br /> for which this permit is issuad. !shaft not omPtoYPersons subject to WORKERS'CDMPl=1l54T;ON Laws of C3f7ornia." Cntfacto's hung or =- <br /> ecntracting signaturecanities tae =o!lowing;'7 certify 072t.n:,y9 eerfornance of Lhe.rork.rv,.4ich rhrs eerrmr i.,;issued. i Shan err�'cy rerscns <br /> WORKS S'COMPE•'dSATiCN--yws o.Californ4- <br /> THE APPLICANT MUST CALL 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIC <br /> TIII2 Consultant 02te 3/23/00 <br /> ji5n4'J' x <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED: G=P <br /> DEPARTMENT USE CNLY <br /> ACDiicauo-Acoeetea 5y -Cate'ssued I I/ri O� ^r <br /> Gout InsP_Ctior By (���lnnn{�i Dafec� L `7 irai Inspeclron 9y D — <br /> Oestruaion ir,soec,iortBy Data -- <br /> COMMENT3 r CONDITIONS: <br /> ACCOUNTING ON!-Y: r AlC�i <br /> °E CODES I FEE INFO AMCJNT REMITTED I CHECK# i RECD BY • DATE I PERMIT i SER'OCS ,REQUEST 0 � )t�'JOICE <br /> I ; SP# CI <br /> C-37 <br /> C-3 LICENSED CU'NTFLkC:TOR 1rIUST SIG',N-I.iCENSE&W0& F-R CO1NPEVSATION DEC:AR.iTION <br /> UNI,-,iV -h/2 i?? /srcn buc.JiME <br /> i <br /> k <br />