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04/12/01 THLi 15:47 FAX 510 6f' 4141 GEOMATRaIX OAKLAND 000 <br /> R p'-Ju <br /> WELL, PERMIT APPLICATION FORM UNI IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES O <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHO) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209Y 466-3449 U)' I Imo. <br /> NONMEEFUNDA9LE PERMIT EXPIPFS 1 YEAR FROM DATE I33UED 2,t,©� <br /> Application is hereby made to San Joaquin Ceunty for a permit to construct ondhzr install the work described, This application is made in=rnplianco with <br /> San Joaquin County Development T1tle, Chapter 9-1115.3 and the Standards of San Joaquin County PubUc t-lealth Services, Environmental Health mvislan, <br /> Assessor's <br /> WELL Location 384r E• d > E. e4 (A.ral 14.1700 ed Cross Street�CatiW-1 Idellea-� City -Tra c.� �p p re ss <br /> PROPERTY Ownerld-.� i XL Trr�a6:Kort DiSV- Address City <br /> C 57 ConVador'tl,r�a;sion w �� Xnc.Address <br /> MOM S. S'n' City :otlm•Ael Zip +IV&q Ut#636362 phoneA d�Z366�f1 <br /> Censult9rrtJ Sub Contractor aaomo}yit CatSqHe..k Address'L LJ� S} City l��te sol Lia# Phenelt ld� 3_�iloo ' <br /> 12 <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> XNEW WELL ORING CPT, GEOPROSS, HYDROPUNCH.HAND-AUGER,OTHER-) 'D;re4+QvSh D DESTRUCTION(choose type below) <br /> SOIL BORING 0 GMx'-I�GMt mal%fir;,, id be- bd.c.kx-411sct a OVER-BORE <br /> WELL h WI"MdAJ-cj a�-Y mens bw hl-,- fd iep D PRESSURE GROUT <br /> -OthB1; 491 i7en+01:4, Pip&40.r60; S-eQ! ' <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> IS MONITORING D HOLLOW STEM DIA. OF BOREHOLE 3„ MULTIPLE CASINGS?Q YES X NO WELL CASING DLA: <br /> — <br /> a EXTRACTION D AIR HAMMMDRIVEN CASING THICKNESS N1AY TYPE OF CASING: p STEEL D PVC D OTHER: <br /> O VAPOR D MUD ROTARY DEPTH OF GROUT SEAL, A44 TREMIE TYPO TO RE USED: D AUGERS DHOSE <br /> D AIR SPARGE PUSH POINT GgZOUT SEAL„PUMPED: Q Yes ]I No (NOTE; MAXIMUM FREE-FALL DEPTH IS,30') <br /> SOIL BORING Q HAND AUGER APPROX. BORING DEPTH 2s' moat. a BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> D OTHER; Q OTHER CONDUCTOR CASING PROPOSED? (it YES, list specs icattons here): <br /> COMlNENTS' D;rcc� P+SE dr 11 f1'� Wi 11 drilt�to„ti0(i Io a WaoA drPtti► a� Z�t i nSl�utl � P i die. FUG CoSinc <br /> 4 Scrr-en 4e All kw'.w o l l bG b m-lCar4 i t ed LJ/ GPn+a g l-PL.'1 F LJ1 a <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby certify that I have prep Ared this application and thattho work will be dotle in accordance with Sart Joaquin County Ordinances,State Laws,and RUICS <br /> and Regulations of the San Joaquin County. htomeawnar ar Rcansed agents signature certirms the rottoWing: "I codify that In the peRormance of the work <br /> for which Ibis permit is issued,I shall not turtp/oy P vMo`n-v subject to WOPX RS'COAWENSA7 ON Laws of Cxlfomia." Contractor's hitirig or sub- <br /> contracting signature Cenifies the following•. '1 ceRlfy ths$XrV the performance of the work for which this permit iv issued,I shell employ persons subject to <br /> WORKERS"COMP 77'ON Laws of Caxfamia,- <br /> T AP CANT MUST CALL 48 HRS IN ADVANCE F R ALL REQUIRED INSPECTIONS, <br /> Signed x title <br /> /z n. /a�et� aeI�o� <br /> SEE SITE MA IN UNIT IV WORK PLAN DATED <br /> DEPARTMENT USE ONLY <br /> ApPIlration Accepted BY Date Issued �O O U Area <br /> Grout Inspection By Date Final Inspectian By Date <br /> bestructlon t Ction By Date <br /> GOMMEIJT9/CONDI71t3NS: �" �� <br /> FAC# <br /> ACCOUNTING ONLY; ALOr <br /> PE CODES FEE INFO AMOUNT REMITTEIS CHECKN/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> N d22� <br /> Ll - <br /> UNiT IV-6/Z3/99!sign bkpg/MY <br /> EA 3Jtid 800-u H.I.JId 6EVE89PEOZ 00 :bT 000E/ZT/tr0 <br />