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10/09/2001 15 47 2094683433 FIFTH FLUUK <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468.3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE I14SUED <br /> Applicabon rs hereby made to San Joaquin County for a permit to construct andlor install the work described This application is made in compliance with <br /> San Joaquin County Development Titie Chapter 9-1115 3 and the Standards of San Joaquin County Public Health Services Environmental Health Division <br /> J J / / I I Assessors -03 d—o <br /> WELL Location_3 lei U lrJ k4,J,, L • Cross Street I�� '�f'ti City�l'dt4 rdo` Zjp �20t Parcel# �r <br /> PROPERTY,Owner CG�>f'ro �`/T �.,y Address 215b w�F 'n p�Cjty SA-Jia— 6p_1E2!_yPhone#?! l-;FVr- W4b3 <br /> C-57Cantraetor _ _y Z�3 ��- Address_ d 'P _City 1v n*AZip' V-MLie#6SLyv'7_Phone#`rss'3+1.3 <br /> Consultantl Sub Contractor 6A fnu�^d"~Addres Jatr .�S City �►�Lrc#7:: Phone#2LYf-97&Z'1j461 <br /> GIS Coordinates X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> *EW WELL f ORING P GFOPRO13E HYDR P NCH HAND-AUGER OTHER") 1]DESTRUCTION(choose type below) <br /> ;"OIL BORING# lT-� OVER-BORE <br /> I]WELL# ©PRESSURE GROUT <br /> 'Other <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING a HOLLOW STEM DIA OF BOREHOLE Z rf MULTIPLE CASINGS?p YES [)NO WELL CASING DIA <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASIKIG 13STEEL Q PVC 1]OTHER <br /> VAPOR a MUD ROTARY DEPTH OF GROUT SEAL "'%A*��_TREMIE TYPE TO BE USED JK?&fsERGJAN­IOSE <br /> Q AIR SPARGE y WIL15H POINT GROUT SEAL PUMPED 11 Yes p No (NOTE. MAXIMUM FREE-FALL DEPTH IS 30') <br /> ; SOIL BORING a HAND AUGER APPROX BORING DEPTH 12o 0 BOLTER TRAFFIC BOX or 1)STOVE PIPE <br /> a OTHER n OTHER CONDUCTOR CASING PROPOSED? (tf YlES,list specifications here) <br /> COMMENTS <br /> NOTE: OFFSITE 13ORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby certify that 1 have prepared this application and that the workwill be done in accordance with San Jo4quin County Ordinances,State Laws,and Rules <br /> and Regulations at the San Joaquin County Homeowner or llcensed agents signature certifies the following 'I certify that In fhe performance of the work <br /> for which this permit Is Issued,I shall not employ persons subject to WORKERS'COMPENSA77ON Laws of California" Contractor's hiring or sub- <br /> contracting signature certifies the fallowing 1 car*that in the performance of the work lar which this permit is issued, I shall employ persons subject to <br /> WORKERS COMPENSATION Laws of Cahfomia" <br /> CALL THEJUNKIV 1NOEC1011 48 WORKING HRS IN ADVANCE F0RAf,1kAtEQU1R)ED INS0ItRTIONSr <br /> Signed x Y! —. Title/Company >✓ �t � ���•`rt •��:raw�.e.-f�-t <br /> Pnnt Name C e I74 eel., Date -10—CJ I <br /> DEPARTMENT USE ONLY L` r <br /> Application Accepted By Date Issued , l pF n R l_p/ _ _- _ Area <br /> Grout lnspeotion By Date Final Inspecbon By Date <br /> Destruction inspection By Dale <br /> COMMENTS I CONDITIONS <br /> ACCOUNTING ONLY Alia# FACS <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK O RECD BY DATE PEAMIT f SERVICE REQUEST# INVOICE <br /> 3SCJ t w dc) r '35 1?1 <br /> 1/18/2000 <br />