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05!04/2000 13:38 20946711 AGE STOCKTON PAGE 02/02 <br /> IUNIT IV <br /> WELL PERMIT APPLICATION260 <br /> FORM <br /> C/ SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> IL I 06 ENVIRONMENTAL HEALTH DIVISION (PHS-EHO) ORIGINAL <br /> o5 '��l 304 E. Weber, Third Floor, Stockton, CA., 95202 /20LCJ <br /> (209) 468-3449 �f <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/or install the work described. This application Is made in compliance with <br /> San Joaquin County Development Title,Chapter g-1115.3 spd the Standards of San Joaquin County Public Health Services,Environmental Health <br /> ekr9'*1 Division. <br /> 3.S• Coin+_, AX41 of We gs�orrs+ • 3z -t0 <br /> WELL LocationSw TeAtrseLTbn Go cLh Cross Street t/Sforr City _1__& ZIP Parcell 05$' e <br /> PROPERTY Owner ElA� J T �4Q_VJQ r Address CVZ! C APr,bC-At.e..city <br /> �•pP� Zip 952VT_phone# 2 7 9 30 <br /> A4NCA* <br /> 0.57 Contractor WEST gAZ Mt;'I•' Addiess323.3 Fitz qE ra)0 City COAyn c, ZIp95`lyLLic#55 9 Phone#orb) 63$ 72.7b <br /> Consultant!Sub Contractor •£ Address 1005 N. l+r lfan4 Crcy S'focX'bn Lid! b A 2 Phone# 2.•4 Yb7-fDob <br /> Saetion _ <br /> GIS Coordinates:X ,y..Township JfJ Ran 9e � <br /> WORK TO BE PERFORMED <br /> ENi WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') 0 DESTRUCTION(choose type below) <br /> 0 OVER-BORE <br /> 0 SOIL BORING#t. 0 PRESSURE GROUT <br /> WELL# <br /> 'Other: <br /> 'znyFor�4+iun mF , <br /> OOMMENTS: V i —Lty4 W W r <br /> TYPE OF WELL INSTALS E CONSTRUCTION SPECIFICATIONS rn <br /> ' vtONITORING hIOLLOW STEtd DIA.OF BOREHOLE $_wr-k_MULTIPLE CASINGS'U YES;a(40 WELL CASING DIAD! <br /> ]EXTRACTION 'PAIR HAMMER/DRIVEN CASING THICKNESS ScN 1t TYPE OF CASING: 0 S 1 tt` U PVC 0 OTHER: TE F]o nl <br /> I VAPOR U MUD ROTARY DEPTH OF GROUT SEAL /.O FF T TREMIE TYPE TO BE USED: UGERS OHOSE <br /> , <br /> I AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: ,'fes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301 <br /> ]SOIL BORING p HAND AUGER APPROX. BORING DEPTH I! 0 IES �ES,`D specifications CBOhe r 0 STOVE PIPE <br /> ] <br /> OTHER:-D OTHER CONDUCTOR CASING PROPOSED.N_(i <br /> tit,, , nODf`AJEfl R� 'u xn work orlon A t n ,I kap z5 Alr'l Ze.A <br /> :OMMENTS: v ft,$l �'Sf Rk C3C-g <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> hereby certify that 7-have prepared this application and that the work will be done in accordance with San Joaquir,County Ordinances,State Laws,and Rules <br /> nd Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: ',I certify that in the performance or the work <br /> or which this permit is issued, I shall not employ persons subject to WORKERS'COMPENSATION Laws of California." Contractor's hiring or sub- <br /> Dr whiting signature t is certifies the following: 'I certify that in the performance of the work for which this permit is issued,1 shall employ parsons subject to <br /> vORKERS'COMPENSATION Laws of California." <br /> ALL THE UNIT IV INSPECTOR 48 WORKING HRS IN ALWANCE RED INSPECTIONS. <br /> FOR ALL REQU1 <br /> y R P�c°�55� <br /> igned <br /> Title/Compan <br /> Tint Nax me <br /> SE SIiNwUNIT N,WOM. PLAN 7 � <br /> s% <br /> / DEPARTMENT USE ONLY O� Area U <br /> �7`�fK' - Date Issued <br /> pplication Accepted By Final Inspection By Dat <br /> rout Inspection By Date <br /> eslruction Inspection By Date <br /> LO <br /> OMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY; AID# <br /> 5ECODES FEE INFO AMOUNT REMITTED CHECK# REC D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 5 0 22 <br /> 1/18/2000 <br />