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' _A2/06/2002 14 57 2094683433 FIFTH FLOOR PACE 02 <br /> { <br /> WELL PERMIT APPLICATION FORM SITE <br /> �11iT}GATfON <br />' <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MM A ENVIRONMENTAL HRALTH DIVISION (PHS-F-HD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br />' NQN-Rr;PUNl3ASLt<PERMIT-EXPIRE�YEAR SROM LSAT ISSUE-D <br /> Applfotlon is hereby trade to San.loaquln County for a permit to eanstrud anwor Install the work descrGed This vi*licapon is ttsade in eompr'=ce with San <br /> Jaaqurt CounW ptwelopmernt Tula,chaptQr 9-1115 a and the Standards of Sari Joaquin Courxty Pdblic Health Sem=r,Environmental Meatth OMZIan. <br /> Assessor's <br />' WELLLoMC013-25-7r Crass street 0' ZZZJ /1Y-Z- G,iy 57?1l.�rYdrD� 7Jp �.�� Parcel# fr9-zoo-y7 <br /> PRCPt=RTYO+�nar,Vtj✓ c'Gl�mt�cy D e:r�CY`Address :�1 11 l..a.« 1a:, Citysem.-m.e zip 9sxo�Phonm# o gY3^(a Y& <br /> ti <br /> C-S7 Cvn=Ctlor OeS-�- H�=�"tet �ACdress 325-7 r'_1'7 "w W=City- 5aG. :ZZlp �{a7 ctr ^ �9 xie;'# �,)� S-7-276 <br /> Constittantf-Sub Carthmcl r.A76 E:?s37 Phone ja S0-cG?z <br /> GIS CoorMnatm X " ;Z' 26r7 ,y 7:?77.r ,Townsh; _ _Ran �� areellan <br />' <br /> WORK 7CO$EPERP'ORt17lED. <br /> 13 NEW WELL!BORING(CPT,GEOPR09E HYDROPUNCH,HANG-AUGER.07HER') DES i RUCMON(=h=ae type befew) <br /> 0$OIL ROP-NG 9_ 17 OVe R43ORS <br /> I WELL p PRessuneCsRQUT <br /> Orcrrt Sper]rigtsans - -- <br /> COMMF. Ts '6eag SEr 4/ 4 Aed"'arGZl✓cGC <br /> ME 0FW5LL !NSTALL4VON TYP CONSYRUCTIDN SPECMC4TIONS <br /> MONITCRING 18OLLOW STEN, CIA.OF 50REHOLE/0 ZNG/I MULTIPLE CAaNGS7 a YES Z hIO WEL CASING DiA - Z-lr' <br /> �0 EXTRACTION 12 A]R HALIMFPJDRIVEN CASING rritCKNES5 Son` HO TYPE OF CASING SSTEHL O PVC [I CTHER'._ <br /> 13 VAPOK Q MUD ROTARY PgRTH OF GROU7 SEALL -;,? da: TRrm"ETYPE TO BE USED, N AUGERS K HOSE <br /> Q AIR SPARGE FUSfi POINT GROUT SEAL PUMPecd- I Yes a No (NOTE; MA?UMUM FREE-PALL DEPTH 15 36') <br />' []SOIL SORI'mc HMO AUGER GROUT SPECIFICATION$ k Z l/b 1. <br /> 3 01 IHR, — APPRCX-5MNG 11 BOL-r8o i tC SOX or D STOVE L='IF'E <br /> CONDUCTOR CAWNr4 PROPQSF-D?(if YES,fist Zpedfi=LJ0ns hers' ., — <br />' •COAglJf1=N75: 2=C ��� S �=D/P �af'Ds��� �ldJ✓i�.r��/L c,/� GdA/;Tier/��D^+/ - � re <br /> Ft?/r i`7d✓f7 <br /> MOTE: OFFSITrz BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br />' CALL THE UNrr IV INSPECTOR 46 WORKING HOUR$IN AWANCE FOR ALL REQUIRED INSPECTIONS. <br /> Y hereby cerbry that I 'have pi-OpBred th)S application and that the work will be-done,n accordance With Sari Joaquin <br /> County Ordinances, Rules srld atians, and all appllcable California State Laws, f �[ <br /> Sr�n>ad x Aa Y.. ✓✓ <br /> Pnnt NaCrze �'w�� 7-- Data <br />' DEPARTMENT USE ONLY <br /> SITE mAP iN UhIIT TY PILE,ADDRESS.- <br />' WORK PLAN DAT W: <br /> AppAcaW AzOePted By r = _. —gate issued <br /> Grout 1 $y Data_—_— Final 1nsperiigr1 By is <br /> �o6ityie$OQ In ?BChdrs SY ate <br /> COIAMEN151CONDITIONS 6z- <br /> e 7=ou"'I1NG 0NLle [A00Ear'-- <br /> P <br /> _PES FEF INFOrvMOLINT REhRt>-r>:D C:HFCK# i2EC D 6Y faATB A!_RharF!s tVtGB I 4t1E5i t141�OIC>` <br /> 3 SOI $`t7 <br />' C�57— W _WAzVER C-57 L-ze er of Atrthoriza'tian'to sign lCraaehment dOr-_ 9/27/00 <br />