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NOV-03-1999 17 30 CAMBRIA INC 1707 935 6649 P 01/02 <br /> • <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> • ENVIRONMENTAL HEALTH DIVISION (PHS-EHO) <br /> 304 E, Weber, Thir4 Floor, Stockton, CA., 95202 O <br /> (209) 488-3449 <br /> NON-REFUNOABLE 1'>`Rf111T PXP1RES 1 YEAR FROM DAT€f&SU <br /> Appi+citicn is h6tvby Made to San Joaquin COunty for a PSM%t to construrt andlor install the work described This appllcatiorn Is made in compliance with <br /> SAA JC&Qurn County Deftlopment Title,Chapter 8.1115 3 and the Standards of San aoagVm County Public HeOM Sakes Envnrwmental Health pttnsaon <br /> WELL Locat)ort re Cross Street Elfitimpt Cid, zip rcehll <br /> PROPERTY Owner ,. dross :Fe las>r sat sLN lrily +en �z�p1700�Phoneie <br /> C-i7CoAtrdttOr Dl <br /> Addreaa4i�e 1.1e�.. Rs.l ClryMar+,mea• Zlpq�SL,Gfl�t p <br /> �srrs hovels t <br /> COrtauftarst r Sub COntrector Address O `N CttY�ir,[�rL,� PhOn#-7,o��9�'Lxt3z <br /> GIS Coordinates X Y Town:titp Range Secltore - <br /> MRK TO BE PERFORMED <br /> It NEW WELL 1 BORING(CPT,GEOPRO13E HYDROPUNCh.HAND•AUGER,OTHER*) a D@STRUCTIDN(Choose type below) <br /> jX501L BORING F -SA-641 Sfs-S S Ix-� Q OVERBORE <br /> -Other �* JEWELL a! - Q PRESSURE GROUT <br /> COMMENTS r- Pr <br /> YYPH OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> JtWONITORING JtHOLLOW STEM DIA OF BOREHOI N MULTIPLE CASINGS-p 0 YES VNO WELL CASING 011.3~ <br /> (I EXTRACTION Q AIR HAMMMORNVEN CASING TMCKNESS�ykTYPE OF CASING <br /> LI STEEL If PVC Q OTHEfL <br /> Q VAPOR p MUD ROTARY 0rmPTH OF GROUT SEAL A-Y3 f kS -TREMIE TYPE TO BE USED 13 AUGERS j f 1oSE <br /> u AIR SPARGE p PUSH POINT GROUT SEAL PUMPED ZYes D No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> 0 SOIL BORING 0 HAND AUGER APPROX BORING DEPTH <br /> j{BOI.7ER TRAFFktr BOK 4r U STOVE PIPE <br /> ER. a OTHER CONDUCTOR CASING PROPOSED_Iyo (rr YE3,Ust apacftWvona here) <br /> COMMENTS <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby cenify that 1 Dave prepared this applmatlon and that the work n,li be done In acmrdanca vinth San lo#gurn County Ordmanves,Slate Laws and Rules <br /> and Regutahons of the Safi Joaquin County Homeowner or GCensed agerifs signature canines the following I certfly that fn the perlbrnrance of the work <br /> fOr which MIS Pwmff Is ISsuad,l shall not employ Persons subject M WORKERS*COMPENSA77ON Laws of Cafffam&" Contractoet;hiring w sub- <br /> contracting signature arUtes the Tollowtnq 1 C"y That m the perfarmanow of the work tar wrath Nis permd a=U&g 1 chap emptor persons subject fo <br /> WORKERS,COMPEWSA770114 Laws of Calr/Orrrra" <br /> fE APP C MUST-CALL 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS <br /> ii � <br /> $I tted — TRIf ` Date <br /> SEE SITE MA IN UNIT IV WORK PLAN DATED: /0 <br /> f � Q �a�� <br /> ApgNlttlon Accepted By DEPARTMENT USE ONLY <br /> Date issuA <br /> ed <br /> Grout Inspedmn By Date Final Inspection By Gate <br /> Dastruftm Inspection By Date �— <br /> COMMENTS/COMDITIONS f •,,$ r <br /> ACCOUNTING ONLY AID* <br /> PE CODES FEE NNFO AMOUNT REM"TED CHECK at R9C'0 BY DATE PERMIT/SERVICE REQUEST* INVOICE <br /> C LYCF ED, CONT ACTON N1VST 4I SIC S ��y _ I PENSATi�I�D> GLARA' 'IDN <br /> -6/23/99/sign bkpg/MY <br />