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C-`, Ely <br /> cz�� � 0 0 COP <br /> - <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> IRE'- _, - ., <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES wn <br /> AUG 15 2001 ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E.Weber, Third Floor, <br /> or, Stockton, CA., 95202 <br /> ENVIRC"',iENI HEFlLTN <br /> PERNIIT,,SER'd�CES <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin Counly far a permit to cons and/or install fhe work described. This application made in <br /> Assessorsntal Health <br /> D with <br /> San Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaaquin County Public Health Services,Environmental HLe/als>th p�lv�ion <br /> /BSoa Sryta�rr /Qon< ro dY tr e £ i Lf•Cily ��G ZP�— <br /> WELL Locallor / ` ( / n/itY i0ZQ Phone# <br /> PROPERTY Ow r ,c �(/'tf/Address �X O�QJ !�f CCO/S�.Cds�n�a q9 <br /> r� <br /> Ci <br /> C-57 0 <br /> , ss / /3 S <br /> E eve�T.CItY�T —LIctF PhonleiF <br /> Add cess/ , l• �. <br /> onsultantl ub Contractor LSectio <br /> n <br /> Y ,Township Z S Range <br /> GIS Coordina as:X t+rltil <br /> WORK OBE PERFORMED <br /> DESTRUCTION(choose type below) <br /> a NEW WELL I BORING(CPT,GEOPROBE,HYDROPUNCH,NAND-AUGER,OTHER-) �pVER-BORE <br /> _O SOIL BORING# PRESSURE GROUT <br /> WELL#_ _ <br /> •Other: <br /> COMMENTS M\Af I MPJ 2. bit nq r-n la( ,e- r r✓ iDrt <br /> e KP S�rrq <br /> o , 6c.7/c(jrys(See ><en�) <br /> TYPE OF WELL INSTALLATION TYPE A CDNSTRUF/fION SPECIFICATIONS <br /> � MONITORiNG O HOLLOW STEM DIA.OF BOREHOLE /Q" MULTIPLE CASINGS <br /> ?? YES ANO WELL CASING DIA: <br /> 0 EXTRACTION O AIR HAMMERIDRIVEN CASING THICKNESS 5 G 40 TYPE TR MEI TYPE TO BE USED: )(AUGERS OHOSE <br /> O VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL <br /> O AIR SPARGE D PUSH POINT GROUT SEAL PUMPED: Yes O No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> O SOIL BORING 0 HAND AUGER <br /> APPROX.BORING DEPTH -Sn >(w l—O BOLTED TRAFFIC BOX or R STOVE PIPE <br /> O OTHER: OTHER CO DUCTOR SIN PROPOSED? "YES.list specifications here): <br /> 2' ZII N <br /> r / <br /> COMMENTSr � c - O a � e <br /> NOTE: OFFSIT BORINGS REQUIRE ACCESS OR ENCROACHMtN I PERM?1S <br /> I hereby <br /> nd Re9certify that <br /> the have <br /> pTJoaquinraCounty.IlHolmeawner or lioensad agent's agnalure ca�mfies thetfollowing'I early that inthepenarrmence of the work <br /> tions <br /> NSATION <br /> contrailrgn3,is alum certifies the <br /> I shall following"[not <br /> caploy rtl7y,that inons subject to rhe performance a the work for whEh this permit s issued,I shall emP GY Pea°ns subject to <br /> 1 PEN rioNr.a 1. ofcerfbm Ip,., ,INAP , g9� a I�D'�N 4 <br /> gigned r CGS TdlelCompany <br /> � 1 yp am i <br /> DEPARTMENT USE ONLYQ A?�/ area <br /> Date Issued l !!O <br /> Application Accepted BY Final Inspection By Dale <br /> - Dale <br /> � r Grout inspection By <br /> Destruction Inspection By <br /> Date <br /> COMMENTS I CONDfTIONS: <br /> ACCOUNTING ONLY: AID# <br /> CHECK# REC'D BY OAS, PERMIT(SERVICE REQUEST# INVOICE <br /> PE CODES FEE INFO AMOUNT REMITTED <br /> 2`t o WI LIDu Z 1/16/2000 <br /> Z0 3JVd <br /> 2100-1d H1dId EE7E89t,60Z TC:VT 000Z/9Z/h0 <br />