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JOIIL oy, ueuoyniec-walnut-creek; 925 943 2365; Mar-17-00 9:17; <br /> bent by: uregg Drilling & Testir, Inc. ; 925 313 0302; Mar-1d- <br /> Page 2/3 <br /> Sont 6y; GvpSyntec-Walnut-Creek 08:09; Page 2 <br /> 925 943 2366; Mar-6-00 1+1:50, Page 2 <br /> WELL PERMIT APPLICATION FORM WUNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHE)) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> N0N-REFUNnABLE PERMIT EXPiR[S YE(tR FROM(RATS 1S8UE❑ <br /> Apps nation s hereby made to San JoaCuln County for a permit to construct andior InstxA the work described. This applttation i,mads to compliance with <br /> Sen Joaquin County Development Tale,Chapte,-9-1115.3 and It,*Standards of San Joaquin County Pubic Htalth So-zes,Environmental Health Divisicr, <br /> WELLLowWonl�l°I Afapr�a.ti S Crow Street Assessor's +k3 2t70^dd <br /> - __..._City S'FO��ZiP °15 6 r.1 <br /> PROPERTYDwngritrAddre55 �'6 3D 15 � aderC <br /> —Citc p 5X5f phone# <br /> C-57 Contractorrtc,fl40.1�i+11tn4 Address_�15Q 1htA' Dol 1�y.� honc#�. 1 alp <br /> ._ .Zip;,*.,- ____�City�f'�1*1C;Z94451 LIC# 1 a <br /> COnStl1tantl5ubCor,tractor(orA,Srtt•t't_CAesKW4vt��,dehess . C. .}�...��� CpY.satr Nu��Lle�.� <br /> C rr>• <br /> GIS Coordinates:% Y Township Range_, Section <br /> (j EW WELL OORWG(CPT, GEOPROSE,HYDROPUNCti,HAND-AUGER,OTHER`) 0 DESTRUCTION(choose type bglc..i <br /> p Soil-BORING e <br /> 13 WELLN d OVER-t30F2E <br /> •Other — -� la PRESSURE OROU7 <br /> COMMENTS: <br /> TYfP�E OF WELL INSTALLATION TYPE CQNSTRUCTION SPEC+FICATMNS <br /> (jMONiTORING #40LLOW STEM DIA,OF BOREHOL��' MULTIPLE CASINGS?WfES ❑NO VVFi_L CASING DIA -� <br /> U EXTRACTION 0 AIR HAMMER1VRIVEN CASING THICKNESS _JQ_,_TYPE Of CASING: <br /> 3 �,- {}STElf: WD- 0 QTNER <br /> 0 VAPOR (j MUD ROTARY DEPTH OF;ORO UT-SEAL - - <br /> -� TREMIE TYPE TO BE USF(7 [j AUC,ERS BFfOst <br /> 0AIR SPARGE <br /> I3 PUSH POINT CROUT SEAL PUMPIFDl 'p yes 11 No (NOTE:MAX(MUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING 0 HAND AUGER APPROX.BORING DEPtH -1 3i,f Ip <br /> f' 0 SCx.TED TRAFFIC BOX or $tTOVE PIPE <br /> 0 OTHER: t_0 OTHER CONDUCTOR CASING E'ROPOSE0T . .(it YES,list spe Cillcalions tiara) <br /> COMMENTS:—kkrtc+. , <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby cartify that f have prepared this appka Ian and that the work vAl be done In accordance With$en Joaquin County Ordinances,Stitiiii Laws,and Rine! ®Q <br /> and Regulations of the San Joaquin County. Homeowner or licensed agent's signature cottifiies the fallowing: "1 cerflfy Ulan in the perflormanee of the wWA <br /> for which lAfs permF1 is issued,I s+ritt not irmplay persons subject to WORKERS'COMPENSATloM Laws of California." GontroCiors ttirira o <br /> contrac*V signarturs Cfrttrteo tho IoNowing 'Y certify Mdf in the AEfformance o(tlle Iwvk for which fhI3 perml'1 is 7y4ued.!3hal1 omplvy par,;pnd jj <br /> CALL THE U IV INSPECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIO <br /> 11 <br /> Signed x ��,i TiilelGonVany� i /� Avf"mrew <br /> Print Name Date <br /> SEE 1A lTE_MAP .tN UNIT ,fY 1�NORK-PLAN C?)�fgf: <br /> 4441._ <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Datil Issued_ (" rC Arca_ <br /> Grout lrlspeclion try (7.: yy���, Date. 'z G 2 ;'fi`;ipinal InspeCiiDn BTr -- Date_._- <br /> DestrucWn 1nloection gy Date <br /> COMMENTS 1 C01,101710N5; <br /> ACCOUNTING ONLY; AID* <br /> PECOD FEE INFO AMOVNT REMITTED CHECK* REC'p BY DATE PERMIT1 SERVICE REQUEST Ie INVOICE- <br /> 1118/20QQ <br />