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WELL PERMIT AP�PLICATION ORM UNIT IV <br /> NOV 16 2001 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION ("PHS-EHD <br /> 'ENVIRONMENT HEALTH 304 E.Weber, Third Floor, Stockton, CA., 95202 <br /> PERMIT/SERVICUES (209) 468-3450 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM MATE ISSUED <br /> Application is hereby made to San.joaqujn County for a permit to construct and/or install the work:descnbad, This application is made in compliance with <br /> pme <br /> 'San Joaquin County Develo nt Title,Chapter 9-1115.3 and,the Standards of San joaquin County:Public:Haalth services.Environmental Health Division, <br /> Assessor's <br /> rcet# 60 9- 16 0_j 9 <br /> WELL Location hwo-i -95 Cross Street 141w, o.,,.- ip.Pa <br /> 13 .N, S city Aci% (zo 9) <br /> OROPE RTY,Owner. :Aq*hf1;:V :Sik,44 —Address, 0, 0 0% 2'+3 5 city I.0_4it Zip 95141 Phone#l!L-2 9 11 <br /> cm57 Contra 104 k 16 <br /> aq tj�4 k t It DW449 Addres 1064151140147101wq)f CityZ-W6"Vo _zip_%610 "1 Lic# PhoneilLl_�-_I S S1 <br /> 15110. tox 609 ity9s( $ <br /> Lic# C_ 1 <br /> 0 3 S !_-5--1 <br /> Consultant I Sub Contractor R M Q F=Iivfrpht�I Address R01C 0 MiAketo, — _5JL_fL Phone# -$A 3% 0 <br /> — <br /> GisCoordinates:X Y—Jownship Fkangs Section <br /> WORK TO BE PERFORMED <br /> &�NEW WEL.L:I.BOAING(CPT,.�.G.E6P.ROf3F- HY0ROFqN.C.H,HAN0-AUGER'.qTHER*) 0.PEST.RV.CTt0N(choose type below} <br /> O.S61L.SOR.[No:# (I OVER-BORE <br /> 4WELL# Rik <br /> I)PRESSURE GROUT <br /> q___ <br /> `Other: <br /> COMMENTS: uvl-_Se movlftWwq we it <br /> TYPE OF WELL CONSTRUCTION TYPE CONSTRUCTION 91 <br /> MONITORING �§.HOLLOWSTEM bF:. OREHOLE I-INCIt MULTIPLE CASINGS-70YES 1.40 WELL cA$INP:D.IA-1J1_1 <br /> EXTRACTION Q AAHAMMERIDRIVER CASING THICKNESS 0—TYPE OF CASING.:. D:pTgEL gPVC BOTHER-_. <br /> VAPOR GERS <br /> ROTARY. -GROUT SEALJ�f�r TREMIE-TYPETO BE USED: fAU._... <br /> . <br /> a AIR SPARGE: U.0iUM00W GROUT.SEAL,PUMPED: I Yes a NoMUM FREE-FALL DEPTHAs 30) <br /> , <br /> :U HAND AUGER A0046x.BORING DEPTH <br /> FIC. X or DISTOVE PIP <br /> 0 SOIL, <br /> UIBORING: CONDUCTOR CASING PROPOSEt)? t �0* .(.itYESi..Iigt,tPod�I tf0ns.hereKR: <br /> COMMENTS: <br /> NOTE:: OFFSITE:BORINGSREQUIRE ACCESS OR ENCROACHMENTPERMITS! <br /> . . <br /> ;e in accordance with San County Ordinances,State Laws,and Rules <br /> thereby certify that:.I have prepared this application and that the work will be do .... .............. <br /> if hjw"of the work <br /> and Regulations of ihe:.San Joaquin County:. Homeowner or licensed agent's signature certifies the following.*Iverdly-1hat 04 O.Pe.".r. <br /> pENSA77ON Laws::Of:CalifoMI4.�o..Cbntf�dtoet.hi.ri.n.g...Or'sub- <br /> subject to WORKMAN'$COM <br /> for which this.peftaft is issued,Jshall not.OMPOY Pe"004 .- I <br /> to <br /> tes the following:"t certify 0 work for which this perm#4A"d,I shall emPbyP66;0ns SuAfect <br /> contracting signaturepertil'i h ce of <br /> f COMOM4 . ..... ....... <br /> WQRKMAW�CO SATIO aw.!o. <br /> D INS <br /> VREQUIRE PECTIO S. <br /> LIC 49 IN ADVANCE FOR AL <br /> Signed x> t <br /> e� <br /> Title <br /> $EE- MAP I.N. UNIT 11" WORK PLAN. Q <br /> ,PJED Awi sl 113 LZ OV 1: <br /> DEPARTMENT USE ONLY coe <br /> Date issued <br /> Application Accepted By, A96t4�tp <br /> Date Final Inspection BY: <br /> Date <br /> Grout inspection By <br /> Destruction Inspedion By Date: <br /> COMMENTS I CONDITION*:: <br /> FAC# <br /> ACCOUNTING ONLY, AID# <br /> UMBER INVOICE <br /> D BY DATE IC9..REQUEST N <br /> PE CODES �FEE INFO AMOUNT RE. <br /> 'le <br /> UNIT IV-6/11/919,lsign bkoQ/Ml <br />