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fit;23"2002 09: '1 2094683433 FIFTH FLLYJR <br /> WELL PERMIT AprLICATION FORM SIDE <br /> SAN JOAQUIN COUNTY M11-1GATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD1 UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 — -- <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT E)'PIRES 1 YEAR FROM DATE ISSUED <br /> 'aL ication is herein made Io San Joaquin County for a permit to construct ano/or In51:311 the work descrit,-d. This aoplic,tion Is rn,tde it compliant. w t,-i San <br /> as juin County'Developrrent Title,Chapter 9-1115.3 and the Slandards of Sar Joaquin County Environmental Haalth D partment. 2--, <br /> VE l Location I-'10 lC AC 6LC Cross SVeetm Y- C ty /--� ZipC/Sf 3��F'sroel#_ /%/ - 2 YG Z- 2- <br /> 'R(,PERTY O'rmeri_C-0 k,STu G 7?e A/ Address 4 6-�-x -,,G City. �?JnL'(' Zips S 3tl R onez j' ��3 /e�r <br /> -5 Contractolf-C-0ddress /yt. C Sd•)It y�\S/ Ciry(LZ�tN'l <br /> 1 �1 Lictl Ph me 7D Z 3 7 SSS 7S <br /> — p T-- _ fl ip <br /> or suttant I Sub;onnttraotor Y L� c� Addret;sA03 14�2 ci1yF» �c;>hl _Phones S�"tS-z d 7 2- <br /> =13 �oordin8te5 X (GSZ' 3 (✓' Y y� fi`� Tcwnship_ ) , S Range_ <br /> (y 4!5sea°on <br /> t\'O tK TO ISE PERFORMED: <br /> NI W WELL BORING(CPT R08E DROPUNCH,HAND-AUG=R.OTHER-) 0 OESTRL,CTICN(choose t}x below) <br /> Q SOIL BORING#_- a OVER-6,AE <br /> 0 WELL K p PRESSL RE GROJT <br /> %710 er. Grout Specific&:ions: <br /> '01RAENTS: <br /> Ye c OF WELL INS to TION TYPE CONSTRUCTION SPECIFICATIONS t <br /> X%A-)NITORING n HOLLO%N STEM DIA OFBOREHOLE /r�S/1-)00L�TIPLECASINGS?Q YES 'XJJO WELL CASING DIA. N/7/ <br /> =? &:TRACP.ON N AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: n STEEL O PVC U OTHEi:• T <br /> L'V)POR 0 MUD ROTARY DEPTH 0=GROUT SEAL 3) / rREMIE TYPE TO BE USED: C)AUGERS HOSE <br /> U U(SPARGE PUSH POINT (TROUT SEAL PUMPED: ),Yes No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> Xt(IL ROPING 0 HAND AUGER GROUT SPECIFICATIONS: — <br /> 3 O'HER: n OTHER_ APPROK a0RING DEPT-1_ 3-0 fl a BOLTED TRAFFIC BOX or 0 STOVE 5 PE <br /> e_ CONDUCTOR CASING PROPOSED? IYU tit YES,list speaFlgtions <br /> ,pp here) _ <br /> 00 AMENTS: G V R U a L D/ tQ�, % P u S h� <br /> _ NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> he-eby certify that I have prepared this application and that the work will be done in at cordance with San Joaquin <br /> �'oi my OrWns, I7and..,Regulations.and all applicable California State Laws.11vi d x1itWGompanyNpme P. u�t YJ/i/Y 6 j —Date— <br /> DEPARTMENT <br /> � �� 2_ <br /> DEPARTMENT USE ONLY <br /> �lri:MAP IN UNIT IV FILE, ADDRESS: <br /> b � <br /> JOHN P. CUMMINGS 1307 <br /> ATTORNEY AT LAW <br /> P.O. BOX 2847 <br /> FREMONT, CA 94536-2847 ] <br /> 10190035-4403 <br /> $ — <br /> GOLDEN FLAY Po.9o.127(650)969Q22 <br /> Monett Field,CA 94035 <br /> 11'00130711' 1: 3 21173561,1: 101 00 5440311' <br />