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12-01-1999 10:08W FROM TO 1559268'7126 p,02 <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> SAID JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (-PHS-E-1-10") <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3450 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE c ISSUED <br /> Apolic bon is hervtsy Rnde to San Jo.-Cuin Courcy to a permit to construct and/or instao the work descnbed. This applicoWn is mace in eorrVftnce with <br /> San Joaquin County Dtveiopment Title.Chapter 9.1115.3 and the Standards of San Joaquin County Public Health Servnes, Environmental fieaRh Division. <br /> Straw22 W. Hammer Lane, #K Mariners Dry Stockton � as x`071-20-14 <br /> Vv"LL Location Cross Stra <br /> I•ROpeRTY own,a0cwen Federal Bank Addrose 1675PalmBeach Lake3.141 Phone# <br /> C.57 Contra=The T•oaining Labs Adder 2527 Fresno St City FresnQ—gp 93721uc* 5061 S�one#559_26 -702, <br /> CcrnsWtant/Sub CortraGorThe Twining Labs ACdresS 2527 Fesno St. City Fresno L P.hone9559-268-702"1_ <br /> GIS CoordinaftCX038°01" N y121°21' 32"W Township 2N Ram 6E Section 18 (shima tra <br /> WORK TO BE PERFORMED <br /> (�f NEIN WELL/BORLNG(CPT. GEOPROBE,KYQROPUNCH. HAND-AUGER. OTHEIR' a DESTRUCTION(choose type below) <br /> IVSOIL BORING L G; ,n ro (l '�) Q OVER43ORE <br /> 0 WELL# a PRESSLZ�E GROUT <br /> ',Itrier. <br /> COMMENTS: <br /> YPE OF WELL CONSTRUCTICN TYPE CONSTRUCTION SPECIFICATIONS <br /> {I MONITORING a HOLLOW STEM DUl OF BOREFfGLE in. MULTIPLE CASINGS?❑Y--S NO weLL CASING 0tA_ <br /> EXTRACTION (J AIR IiAMMERIOR"N CASING TNtCKNZ" n a TYPE OF CASING: 0 STEL rI PVC Q OTS <br /> o VAPOR 0 MUD ROTARY DEPTH OF GROtT SEAL n a TR�1=_TYPE TO dE USED_ a AUGERS OHCSE <br /> 0 AIR SPARGE 0 PUSI4 POINT GROUT SEAL PUMPED: a Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH tS 30') <br /> ,)(SOIL BORING 0 }LAND AUGER APPROX. BORING DEPTH a SOLTI✓D TRAF-MC BOX or a STOVE PIPE <br /> 0 OTHER CONDUCTOR CASING PROPOSED) {If YES,Rrsi spec ficabonb mere): <br /> COMMENTS:_ passive Soil Vapor Survey 13-1"x3' points <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS! <br /> hereby certify that I neve prepared this application and that the wont will be done In accordance with Sam Joaquin County OtdawnceS,State Law,and Rules <br /> and Regulabom of the San Joaquin County. Homeowner or licensed agent's signature certifies ttre f090wing 41 certify that in the performance of the wont <br /> for whicn MIs permit is lssuec�l shall rrot ernpiay persona subject to Wt7RKJMAN'S COMPENSAITON L.awa of California' Contractcro hiring or Lub- <br /> contractinq siorsatttro certifies the following: 'I certify that in the pwI1orraarce of the world for wtIx;ft d is pmn*is iggued /$no employ Persarts$L00a to <br /> WORiciuWS COW-ENSATION caws of Ca/ilomia_' <br /> THE APPLICANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed / �• title '��0�' Rco /Sr>� Osie ZI2 /OZ <br /> SEE SITE MAP IN UNIT IV WORK PLAN. DATED "y`-- ld- - '9-0-00 !L�``� <br /> 0"ARTMrIIT USE ONLY u <br /> Apokotion ACxpteC 9y `�/t�`7. c--,4;;:::: 02te Issued ( / `J,— ��D Area <br /> Grout Inweetkx BY Date F'tnat Insoection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: �„ t'1% ,ca - �_��>��_->- <br /> ACCOUNTING ONLY: AIDR <br /> FAC# <br /> PE CODES FEE MFO AMOUNT REmin CHEC CASH RECEIVED BY DATE I PERMIT/SERVICE�REQUEST NUMBER INVOICE <br /> UNIT IV-5/99/MI <br />