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05/10/00 WED 17:27 FAX 510 E'' 6350 GEOMATIZIX FILE <br /> OAKLAND -up <br /> vow, Y <br /> WELL, PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY P_UBL,IC HEALTH SERVICES �J71'�-lJo <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) Q <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209Y 468-3449 Cp�ROGlJ�� <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR.FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct and/pr install the work described. This application is made in compliance with <br /> San Joaquin County Development Title.Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division, <br /> S. en Assessors <br /> WELL Location W. l I'b .Sirf,94, Trac! LA Cross Street Qwo-A(;ela City Tragi Zip jQ1A, Parcel# <br /> � 5 <br /> PROPERTY Owner City 6.t -7-ram., Address ­r-30 Ylw c; B WA- City Tj CL cx ip Phone#_{2o9) ) y y 2.o <br /> C-67 Contractor Plee isiM Sd»P1 Yat_Address /1100 S„ 5-6'6 SIfee.i!. City..gticMNwaa Zip_V&1j_Lic#6 63 Z Phone# <br /> Consultant/6w6-Qaat=Ct=6e01"mA W 4ASu "24. S Address 2101 We.b 4ew SI•- City'&lmk" lie# Phana#6S-)of 663-1/1oo <br /> wcl, fry.- <br /> GIs <br /> ry.GIS Coordinates:X ,Y Township Range Section <br /> WORK TO BE PERFORMED <br /> BORING GPT•GEOPROSE,HY ROPUNCH.HA -AUGER,OTHER-) - D:ra-4 FPS6 (f DESTRUCTION(choose type below) <br /> Q SOIL BORING GE <br /> - t bw«1 yF Ieaekl �tleel w;/tt Q OVER BORE <br /> Q WELL# CoQ PRESSURE GROUT <br /> 46-8-+ 70'0,.Pe.1;fin a Ti�iH:e i e. <br /> 'Other. <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Q MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE " MULTIPLE CASINGS?o YES )(NO WELL CASING DIA-- <br /> 0 <br /> IA:0 EXTRACTION Q AIR HAMMI;R/DRIVEN CASING THICKNESS "'A TYPE OF CASING: I]STEEL Q PVC 0 OTHER; <br /> (]VAPOR o MUD ROTARY DEPTH OF GROUT SEAL AM TREMIE TYPE TO BE USED: Q AUGERS QHOSE <br /> QAIR SPARGE PUSH POINT GROUT SEAL PUMPED: Q Yes �(No (NOTE: MAXIMUM FREE-FALL DEPTH IS.30'1 <br /> SOIL BORING Q HAND AUGER APPROX.BORING DEPTH 2S Q BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> Q OTHER: 0 OTHER CONDUCTOR CASING PROPOSED? (It YES.list specifications here); <br /> COMMENTS: posh r-3 tj;i) sj.-UU-& .. r So'l /b 21— 1 iASIuM fe4u l'�et'4 Pvc rasini W/E, Scrt� <br /> _... '�^vP-lr 7►r��n,der...�n. �ernu �o be, boe.tc�ifttd W�fin. Ge�Yrayj- ylo�f of•f-41 ?irw+.i.e �iAe <br /> NOTE. OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,State Laws,and Rules <br /> and Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: "I certify that in the performance ofthe work <br /> for which this permit/s Issued,I shall not employ persons subject to WORKERS'COMPENSATION Laws of California." Contractor's hiring or sub- <br /> contracting signature certifies the following: 'I certify that In the performance of the work for which this permit is issued,I shat/employ persons subject to <br /> WORKERS'COMPENSATION Laws of California." <br /> THE APPLICANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> / <br /> � fog <br /> Signed z ��Jra ..,�,. Sw. i—i— ✓ �"t/4 _—Title Lf*te+ Date Szw <br /> SEE SITE MAP UNIT IV WORK PLAN DATED <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Issued J s�� Ala <br /> Grout Inspection By Date Final Inspection By Date -- <br /> Oestruction Inspection By D to <br /> COMMENTS I CONDITIONS: <br /> .i 350' w <br /> FAC# <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKII/CASH RECEIVED BY DATE P5AMIT/SERVICE REQUEST NUMBER INVOICE <br /> ?SI D I 5100 ��• 'l l ��ZZ 29 <br /> UNIT IV-6/23/99/sign bkpg/MT <br />