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63/16/2000 08:43 2094683433 FIFTH FLOOR, PAGE 02 <br /> r ly/ <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> D - I�r� <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-END) JAN 0 3 200] <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (las)468-3449 ENVIRONMENT HEALTH <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT/SERVICES <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. ThLs application is made in compliance with <br /> San Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services.Environmental Heafth Division. <br /> WELL Location Sz'r�t Cross Street���City-J�' zip�VAssessors Z( <br /> �^ �u / 5.30 ParceNt <br /> pROPERTY Owner I P_n(f M (!'�DOf tv Address 0q/ F St_ City,'64.7 tS Zip�,��Phonail X09- ��3=zJJO <br /> C37Contractor_46 ;fVGP� ln/A _Address Pa- O ( 336 CItyRo 1/04 ip S71Lidi�QQj�Pnone#7D7 37�, y;fly <br /> Consultant I Sub Contractor Address 29V x 1#fw/soM 15(✓ City l ,I Aiiifj Lint Phone# Tlb-,,�.J', --eF On <br /> GIS Coordinates:X_ Y Township /rr Range S¢ct;en <br /> WORK TO BE PERFORMED <br /> KNEW WELL/BORING(CPT.GEOPROBE,HYDROPUNCH,HANO-AUGER,OTHER-) p DESTRUCTION(choose type below) <br /> 0 SOIL 130RING# 0 OVER-SORE <br /> 'Other. <br /> DWELL# eZ 0 PRESSURE GROUT <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS I i 4t. <br /> 0 <br /> t- <br /> 0 MONITORING HOLLOW STEM DIA.OF BOREHOLE S.r MULTIPLE CASINGS?BYES SNO WELL CASING DIA:_ti U/Yoel <br /> X EXTRACTION Q AIR HAMMERIDRIVEN CASING THICKNESS sth• y TYPE OF CASING: U STEEL A PVC BOTHER: <br /> X VAPOR C MUD ROTARY DEPTH OF GROUT SEAL 3- TREMIE TYPE TO BE USED: JAUGERS CHOSE <br /> p AIR SPARGE C PUSH POINT GROUT SEAL PUMPED: D Y s No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> B SOIL BORING U HAND AUGER APPROX.BORING DEPTH r filiOLTED TRAFFIC 13OX or C STOVE PIPE <br /> p OTHER: n OTHER CONDUCTOR CASING PROPOSED? P0 (11 YES.list specifications here): <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby certify that I have prepared this apprication and that the work will be done in accordance with San Joaquin County Ordinances,State Laws,and ides <br /> and Regulations of the San Joaquin County. Homeowner or licensed agents signatureeertitles the following:1 eeraily that in the perfannanee of the work <br /> for which anis permit is lasuev,I shall not employ parsons sub/eel to WORKERS'COIKPENSA770N Laws of California." Contractor's hiring or sub- <br /> contracting signature oertifies the following:7 oertny Qtat in the PerfiNmanca of the work for which this parmk is issued,f shall employ persons subject to <br /> WORKr:RS'COMPENSATIONLaws of California." <br /> :CALL<'hE IiTllJ$ ETOR INQFtI±�ll l ]�RBiN'ADt(1N>�E ` L+ 'iiiEOtN <br /> Signed xTitle/CompanY Angir-r4 7 <br /> A/ aYf(J/� c v <br /> PrintName GI S. _6OOl e t j<_ Date <br /> ,.,_f/�r.1,,- OEPARTIMENT USE ONLY h 1 <br /> Application Accepted B aS �Yli\ Date Issued_ lJ i Area <br /> Grout Inspection ByY031e Final Inspection By Data <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES I FEE(NFO AMOUNT REMITTED CHECK it RECD BY DATE PERMIT/SERVICE REQUEST* INVOICE <br /> Z <br /> 3/ls/z000 <br />