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10/69/2901 15 47 2694683433 FIFTH FLOOR NAG/ 01 <br /> ,,Post-rl'Fax Note 7671 Date I p e 01 pa°%s11- Z <br /> To f From \ <br /> Dept Co T- -& PLICATtQN FARM UNIT IV <br /> it Sne N Phone It i7 f d33 <br /> a 5' Fax 11 UBLIC HEALTH SERVICES <br /> -TH DIVISION (PHS-EHD) <br /> 304 E Weber, Third Floor, Stockton, CA , 95202 <br /> (209) 488-3449 <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 De)MbVnent Title,Chapter 9-1115 3 and the Standards of San Joaquin County Public Health Services Environmental Health Division <br /> �/u // I . ) / 4��� Assessors <br /> WELL Location 7 L -+1A.l ��` W1 Cross Street i. �h SA City �► Zip iJ�'96 Parcel# & A_Off~O <br /> 11 I I <br /> PROPERTY Owner S�^fin G' fit! Address �G1&r K 9'tCdy f�' -��-'ZiP[5 7Phone <br /> C 5T Contractors Z of•Fu ^Address City/ ^t;Z ZipL .z L' L 50-1Phone# —313' W <br /> Consultant Sub Contractor .+. <br /> .rw�"Address r/Lcr wS ST City ^,c_Lic# Phone#i 7Lb7- <br /> GIS Coordinates X Y Township Range, Section <br /> WORK TO BE PERFORMED <br /> NEW WELL BORING CR GEOPROBE,HYDRO NC HAN U R OTHER") 0 DESTRUCTION(Choose type below) <br /> �,SOiL BQRING# ` CPU� a OVER-BORE <br /> WELL# �]PRESSURE GROUT <br /> 'Other <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Q MONITORING 0 HOLLOW STEN/ DIA OF BOREHOLE­2 ! MULTIPLE CASINGS?]]YES. (INC) WELL CASING DIA <br /> 0 EXTRACTION 13 AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING 13 STEEL a PVC 0 OTHER <br /> VAPOR 11 MUD ROTARY DEPTH OF GROUT SEAL gA. -LiO - REMIE TYPE TO BE USED %^b1GyEf25p�AWOSE <br /> 6 AIR SPARGE PUSH POINT GROUT SEAL PUMPED XYes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> ,SOIL BORING p HAND AUGER APPROX BORING DEPTH '17 (1 BOLTED TRAFFIC BOX or U STOVE PIPE <br /> 0 OTHER n OTHER CONDUCTOR CASING PROPOSED (I YES,list specifications here) <br /> COMMENTS <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby certify that 1 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 of the work <br /> for which this permit is issued,t shall not employ persons subject to WORKERS'COMPENSATION Lacks of Calltbmia ' Contractor s hiring or sub- <br /> contracting signature certifies the following 7 certify that in fhe performance of the work for which this parmrl a issued t shall employ persons subject to <br /> WORKERS COMPENSATION Laws of Cahfomia" <br /> CAALL'TIJF.UNIT IV r__INSPECTOR &WOFtk1Kq H$0 IN ADVA/NCE'FOftk/�L/ft)EQUIRED INI$�)�CTIONS fes-! <br /> Signed x / r7 'Y Title/Company re[e is C ta._le.: �',",lro...•.e... <br /> Print Name Date Z <br /> DEPARTMENT USE ONLY <br /> Application Accepted By CLn Date Issued 4� as_ <br /> Grout Inspection lay Data Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS <br /> ACCOUNTING ONLY AtD# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# R D BY DATE PERMIT I SERVICE REQUI=8T# 1NVOICf; <br /> iso4y set <br /> 1/18/2000 <br />