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05/014/2000 13:38 2094671• I AGE riTOCKTON � FILE COPT2 <br /> WELL PERMIT APPLICATION FORM UNUM V� <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> D I" ENVIRONMENTAL HEALTH DIVISION (PNS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA,, 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 7 <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This applicatlon is made in compliance with <br /> San Joaquin County Development Title,Chapter 9-1115.3 0pd the Standards of San Joaquin 3•`r' Cove+ Qir�l}-T OF i+raY c SlOrf 8f pts• q County Public Health Services,Environmental Health Division. <br /> WELL Location-F.W. �I9te ie von —Cross$treetc�1LCity�A1 Assessor's At944 aF u.-t <br /> PROPERTY Owner FIA6 r!T��Oy(O r'� Address- 6V2f CAPi,6LA,e CB � Zlp Parcew�5 1. - zS <br /> y-- ZP p52y2^Phone# 7 9 30 <br /> C•57 Contractor wES'T {•)py ,y, ,L Address 3233 Kid a] RANaNe <br /> /� City CnrQAe�.P ZipTj 7y�ic#SSyf7Q Phone# 6 63 Z b <br /> Consultant/Sub Contractor A . Ct .� .T Address �0 0 5 (V tv i 1L+^L c Sr <br /> p y--.3i L7c# 6 0 2 Phone#Za Y6'7-1o�S, <br /> GIS Coordinates:X.,Y ,Township 3r%) Range ,5'E <br /> angeSection � <br /> WORK TO BE PERFORMED <br /> �}EW WELL/BORING(CPT, GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) <br /> 0 SOIL BORING# 0 DESTRUCTION(choose type below) <br /> WELL# MLU. p 0 OVER-BORE <br /> 'Other: p PRESSURE GROUT <br /> COMMENTS: �n5.*01NU i an 4b <br /> MvJ� I -•Le.,el wLll aa�n� <br /> rYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> �v10NITORING `-e..OLLOW STEM DIA.OF BOREHOLE$ J, MULTIPLE CASINGS?p YES��',`40 WELL CASING DIA: t .IAch <br /> ]EXTRACTION HAMMEWDRIVEN CASING THICKNESS ScN It <br /> NIR TYPE OF CASING: T <br /> ]VAPOR O S EEL 0 PVC 0 OTHER: T G1aoJ <br /> 0 MUD ROTARY DEPTH OF L OUTPUMPED: <br /> SEAL D FE.ck TREMIE TYPE TO BE USED: �p,UGERS pHOSE <br /> ]AIR SPARGE p PUSH POINT GROUT SEAL PUMPED: .& es p No (NOTE: MAXIMUM FREE-FALL DEPTH 1S 301) <br /> ]SOIL BORING a HAND AUGER APPROX. BORING DEPTH- /$0 F£fa- A <br /> -� OLTED TRAFFIC BOX or 0 STOVE PIPE <br /> ] <br /> OTHER:.0 OTHER CONDUCTOR CASING PROPOSED? 0 <br /> _ (if YES, list specifcalions here):_ <br /> :OMMENTS: �IRpjjj4� (,_�{�AGg D NC�IFt1 R c •w <br /> —t- W o r is ,nla n A a a e a _drt�o zs qp. , <br /> Ze�r� <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> hereby canify that I nave prepared this application antl that the work will be done in accordance with San Joaquin County Ordinances,State Laws,and Rules <br /> Dr <br /> Regulations Of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: "1 certify that in the performance of the work <br /> or which this permit is issued,/steal/not employpersons subject to WORKERS'Cgh1pENSATION Laws cf California," Contractor's hiring or sub- <br /> VORKting$ignature certifies the following: "1 certiry that in the padomrance of the work far which Ih/s pemtir is issued, l shall emptoy persons subject to <br /> YORKERS'COMPENSATION Laws of California." <br /> ALL THE UNIT IV INSPECTOR 48 WORKING HRS INA ANCE FOR ALLQ REQUIRED INSPECTIONS. c <br /> ine --/^• - Title/Company C l?0/Q YD�Cel7 G o <br /> tint Name <br /> me <br /> SE SITS", MAS 1 Date/A o <br /> N UN IWC WQRKPLAN <br /> DEPARTMENT USE ONLY �c,�y/ <br /> routPiPliI tion Accepted ey �O�l r�i/ <br /> Date Issued LJ Aree_(Yne G <br /> rout Inspection 8y. ,_,^_pate Final Inspegl0n By <br /> eslruction Inspection By Date <br /> Date <br /> OMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY; AID# <br /> �S CODES FEE INFO AMOUNT REMITTED CHECK# <br /> RECD By DATE PERMIT/SERVICE REQUEST# INVOICE <br /> ✓`' 002z�53 <br /> 1/18/2000 <br />