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NOV-03-1999 17:30 CAMBRIA INC. 1707 935 6649 P.01/02 <br /> WEL.,PERMIT APPLICATION FLaviM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHO) <br /> 304 E. Weber, Third <br /> (20) 468-3449kton, CA., 95202 FILE COPY <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> AppliCatlod is hereby made to San Joaquin Courtly for a permit to=ntltrui aodier Insta0 Inc work descnpad. This application is made in compliance wqh <br /> San Joaquin County Development T1Ue, Chapter U-1115.3 and the Standards of San Joaquin County Public Health SeNIces,Environmental Health Division, <br /> WELLLocatlon 2494 FprmsnrL Se --1 Cross Street E;1Lr + Clry S}Ock}oh ZI Assessoq <br /> P parcew <br /> PROPERTY Owner Fess; lam �.� F ti Yt Address Sv,fc Ior4 on<S41( Ry Ne+s{.aA Zi 7700 <br /> I P Phone* <br /> C-57 ContractorG y -- Address 95e WaUr R'.J. CiryMdt-t_.L ZI 6M;l Licy4 P r.:JT <br /> //11 aS hones fss)t1 Ssee ;p'�. <br /> Consultantl Sub Conpactor_C.,Lk.`st Address,210 Prrlr�.rS 4T Ciry SoyrnC�Lic* <br /> Pnonr*7oT 93T.7tSa <br /> GIS Copmmates. X , Y ,Township Ran <br /> 9e Section <br /> WORK TO BE PERFORMED <br /> It NEW WELL/BORING(CPT, GEOPROBE. HYDROPUNCH,HAND-AUGER,OTHER-) <br /> SOIL BORING a SR-4 SK- SR• U DESTRUCTION(choose type below) <br /> A WELL S_,�j -y 0 OVER-BORE <br /> -Other `% - 0 PRESSURE GROUT <br /> COMMENTS: <br /> P OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> XWONITORING $HOLLOW STEM DIA.OF BOREHOLE ' MULTIPLE CASINGS,0 YES VNO WZ <br /> WELL CASING DIA_ � <br /> 0 EXTRACTION 0 AIR HAMMERIDRNEN CASING THICKNESS-Q'01"y¢TYPE OF CASING: 0 STEEL A(PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SSAL'- t/3 P TREMIE TYPE TO BE USED GAUGERS gF105F <br /> p AIR SPARGE p PUSH POINT GROUT SEAL PUMPED: ,ZYes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER APPROX BORING DEPTH r112-(IS fl* ItSOLTED TRAFFIC BOX Or <br /> 0 OTHER._13 OTHER CONDUCTOR CASING PROPOSED 0 STOVE PIPE <br /> -�_(it TES,1191 specifUtgna hereJt <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby ceC'ty that I have prepared this applicatlon and that the work will he done In accordance with San Joaquin Counly OrdinanRs, State Laws,and Rubs <br /> and Regulalions of the San Joaquin County. Homeowner orJlCensed ayeM'e signature certifle6 the followln <br /> for which this permit la Issued,/shall not rm l0 g: ,.t certNY that in the Pe'1bmnsnee of the work <br /> contracting signature caR.Yros the following:-1 esefily that i the performance of fhe w kCtw hich inis pamut 4 issusdll shah em 1Oy P oto nur's hiring ct 0 <br /> WORKERS*COMPENSA 77ONLLaavz of Cefifornia." P YPezPns subject fo <br /> /�/y�� EE APP MUST.CALL 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed 4!�/�i Trfe-Pka,!C!-i Pate <br /> 11 13 111 <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED- ly -/5-1 <br /> DEPARTMENT USE ONLY <br /> ApplleInspItIon Accepted By Date Issued L/� 4 �// Ana <br /> Grout Inspection By _ Date Ftnaf Inspection By <br /> Destruction Inspection By Data <br /> Date <br /> COMMENTS/CONDITIONS: f '`SYr' <br /> ACCOUNTING ONLY: AIDS — <br /> PE CODES FEZINFO AMOUNT REMITTED CHECKS REC'O BY DATE PERMIT!SERVICE REQUEST f INVOICE <br /> 350 t ¢S' /t Z D <br /> C•37 IlCENSED CONTRACTOR MUST SIGN;LICENSE:&T4' qQW,ENSA11ON DECLARATION <br /> UNIT IV-6/23/99/sign bkpg/MI - <br />