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03/16/2000 08:43 203468343 FIFTH FLOOR, PAGE 02 <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 /> (las)468-3449 <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 Development Titt2,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services.Environmental Heahh Division. <br /> /iI� " Q p Assessor's <br /> WELL Loratlon_ S 'T.��1 !>� . Cress SStreet t City_ f7 � Zip ",1f�- Porcelli ZSO-C� 00-(� <br /> PROPERTY Ow11n--e``r_iJ-bbl t P X6CL gtldress J S i F __City_1T-r Gl _ZiP_I�Jt�hone#_ t <br /> C-67 Contractor lLAd Pfl_ I�Address 2,3 J Clly � Tra.Zip LLiC#1Le.'Phone# 7 "130 <br /> Consultant i Sub ContractorTr--Yl\ .rD4-e& Address 779 q4 M1645M Cityj L 0AiIGS Lie# Phone#Lql�o)5 35�0��00 <br /> 6FG t <br /> GIS Coordinates:X Y Township 2S Range 56 Section 1-14 <br /> WORK TO BE PERFORMED <br /> )QNEW WELL/BORING(CPT.GEOPROBE,HYDROPUNCH,HANO.AUGER.OTHER-) p DESTRUCTION(choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE <br /> 'Other, SELL 0 PRESSURE GROUT <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING ,HOLLOW STEM DIA.OF BOREHOLE J/ MULTIPLE CASINGS?0 YES KNO wELL CASING DIA: <br /> 0 EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS�2C, LEO TYPE OF CASING: 0 STEEL JKPVC p OTHER: <br /> 0 VAPOR C MUD ROTARY DEPTH OF GROUT SEAL 2—t4e TREMIE TYPE TO BE USED: .(AUGERS OHOSE <br /> 0 AIR SPARGE o PUSH POINT GROUT SEAL PUMPED: 11 Yes Z�No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> 11 SOIL BORING 0 HAND AUGER APPROX.BORING DEPTH Z9)r BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> p OTHER: D OTHER CONDUCTOR CASING PROPOSED?(I 0 (If YES,list specifications here): <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby certify that I have prepared tnls apprrcetion and that the work win be done in accordance with San Joaquin County Ordinances,State Laws,and Rules <br /> and Regulations of the San Joaquin County. Homeowner or 11censea agent's signature certifles the following:1 cewffiy that in the performance of the work <br /> for which this permit is Issued,i shall not employ persons strblect to WORKERS'COMPENSATION Laws of GWifomila." Contractor's hiring or sub- <br /> contracting signature certifies the following: 'l car*that in rhe performance Of the work for which this permit is issued,I shall employ persons subject to <br /> INORK1=RS'COMPENSATIONlaws of Catifomla." <br /> ALti:: ! X+IWiiNSPi= 'CflR ` Q III + J QRSiN ADVANbIRE� M#Li�CE �- <br /> Signed x Title/Company1n S f IC "GGc yc, <br /> Print Name QJCy Date 0 <br /> �y►�� f'DEPARTMENT USE ONLY <br /> Application Accepted By f ' Q'1.��t Date Issued 2 Id-I 00 Are. `I <br /> Grout Inspedion By 03le Final Inspection By Data <br /> Destruction Inspection By Dale <br /> COMMENTS I CONDITIONS= C I i ( Mb R 7;(1 I= SL(q tr <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK* REC'D BY DATE PERMIT l SERVICE REQUEST# INVOICE <br /> 35ot <br /> Z/28f 2000 <br />