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12-01-1999 10:08P1M FROM TO 15592G8?126 P.02 <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> SAM JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION ("PHS-EHE") <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3450 <br /> NON-RI FUNDABLE PERMIT EXPIRES 1 YEAR FROM DA7=-c ISSUED <br /> Apo$=Gon is horot>y gado tc San Jo auin CCunty for a permit to COnstnrd and/Or in=O the work des=be-d_ Trus app6c oWn i5 rnade in Compigrvoe with <br /> San Joaquin C4ur4y Oeveleprnent Title.Chante*4.1115.3 and the StandardS of San Joaquin Courtly Pubr,G Health ServkeS, EnviMnmentat Health Divi r <br /> 3422 W. Hammer Lane, rKG oss S Mariners Drueet ay Stockton � Pante es 071-20-14 <br /> WELL Location <br /> l•ROpER-ry O,wr,er0cwen Federal Bank Adcross 1675Palmi3each Lake�CityW_PalmBeaC '�?401 Phone# <br /> S-57 Contractor The Twining Labs Addres3 2527 Fresno St City Fresh IIo 93721tjcr 50h1 SgaTone#55�68-7021 <br /> Consultant/Sub Corn=r The Twining Labs _Address 2527 Fesno St. City Fresno Le_— P.tor_-9559-268-702'_ <br /> GIS CoorfllnatftK X 038°O1" N Y 121°21' 32"W Township 2N Range 6E Section 18 (shima tra <br /> WORK TO BE Pr=Rraf mCo <br /> NEN WELL/BOR:-IG(CPT.GEOPROSE,HYOROPUNCH.HAND-AUG-,R. OTHER-) Q aEsTRucnON(moose type below) <br /> SOIL BORING t C;Pc�j rnjl p U 3) 0 OVER-SORE <br /> Q WELL;I <br /> Q PRESSURE GROUT <br /> -Outer. <br /> COMMENTS: <br /> TYPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STsM CIA OF BOREHOLE in- MULTIPLi=GA_SWG5?❑r.5 NO WELL GA31Nc3 Ot^ <br /> EXTRACTION 0 AIR KAMMERIOR"-N CASING 7'H1CXr F_3S n aTYPE OF CASING: Q ST_E Q PVC Q OTH� <br /> 0 VAPOR 0 MUD Rt7TA.RY DEPTH OF GROUT SEAL n a TREMIS TYPE TO RE USED_ p AUGERS aHCSE <br /> p AIR SPARGE Q PUSH POINT GROUT SEAL PUMPED_ C Yes 0 NO (NOTE: MAXIMUM FREE-FALL DEPTH IS 301 <br /> ',SOIL BORING Q '-IAND AUGER APPROX.BORING OV7TH a BOLTS TRAF-FIC BOX or 0 STOVE PIPE <br /> o OTHER: CONDUCTOR CASING PROPOSc3? (If YES.frst 30ecMq-3b0ns here)' <br /> COMMENTS, passive Soil Vapor Survey 13-1"x3' points _ <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS? <br /> ! "reby c9dify ttUt I h2ve prepared this aopl,pt m and that the wom win oe done m accordance witA San Joaquin County Ordin�s,State Law&,and Runes <br /> and Regulations of the San Joaquin County. Homeawnfr of 50en3ed agent's signaum certifies the fosowinT It c*tdfy that in the performance of the work <br /> for wt?lch MIS perp is issued f snail not employ persons subicct to VMRKIMAMS COMPENSATION Laws of California.' Controetort hiring w sub- <br /> cnntractim sigrssture certifies the following: '/Caring that in dhe perfomume of the wo►x for wllicn flus permit is Issued /shalt emPfay persOM suDliECt tc <br /> WORKMAN'S COAD.NSATION Laws of CatiYom ' <br /> THIIE APPLICANT MUST CALL 48 HRS 1N ADVANCI: EOR ALL REQUIRED INSPECTIONS. <br /> signed I ��l/"t. Atte deo i k_ Gate Ll 2-10-D <br /> `r GL,il�'L`Y7 ✓4SS-LES lL.y� <br /> SEE SITE MAP IN UNIT IV WORK PLAN. DATED <br /> t)ePARTMENT USE ONLY <br /> Apo6octionAOoepted h �/�� Date Is4r,ed Y -/ - C�v Area Lt Y <br /> Grout Insaectieg BY Date Final lnsoection By Date <br /> _Destrud'tort Inspection By Date <br /> COMMENTS I CONDITIONS: 1 c = <br /> FAC# <br /> ACCOUNTING ONLY: AIDd <br /> PE CODES FEE FIFO AMOUNT REMITTED EHEC \CASH RECEVED BY DATF_ � PERMIT/5EiVICE REQUEST NUMBER INVOIC <br /> 1���( �S0S l <br /> UN17 IV-5/99/MI <br />