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03/16/2000 08:43 2094683433 FIFTH FLOOR PAGE 02 <br /> WELL PERMIT APPLICATION FORM ' UN11 IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES �� <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 1 2000 <br /> (209)468-3449 ENVIRONMENTAL In zALTH <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. This 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 /> 54 t Fs�Lfeet 4 Assessors <br /> WELL Locetlon 'ry Cross Sheet � '" city-991)4A->,,._� Zip �J� D Part 2�-0�-Z <br /> PROPERTY Owner ���1 moo Address ��� I �` Sfi City_ I�:..Zipl�J.&_Phoned/?tea $' 27 5 <br /> C-57 Contractor1.(�DtrAr[VJaj_GI Dl lingAddressPO ft 33lo Ctty w V, Zip!{51(Lich t eL7 Phone#17y7)3�}-�30D <br /> Consultant I Sub Contractor/4P4!,K 6YIVIV't4eCh ddress 79gq 0741S017 406 CityF LIUF Phone# -&2 555'oZoo <br /> We 4940 4 <br /> GIS Coordinates:X Y Township Z S Range S E Section—Z <br /> WORK TO BE PERFORMED <br /> NEW <br /> WELL/BORING(CPT.GEOPR08E,HYDROPUNCH,HAND-AUGER.OTHER-) Q DESTRUCTION(choose type below) <br /> SOIL BORING# l 0 OVER-BORE <br /> ELL# 3 Q PRESSURE GROUT <br /> 'Other. W <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING VHOLLOW STEM DIA.OF BOREHOLE_&_MULTIPLE CASINGS?i1 YES1V0 WELL CASING DIA:2 <br /> g EXTRACTION Q AIR HAMMERIDRNEN CASING THICKNESS64k L�2 TYPE OF CASING: 0 STEEL b(-VC p OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 2---4" TREMIE TYPE TO BE USED: `AUGERS OHOSE <br /> Q AIR SPARGE Q PUSH POINT GROUT SEAL PUMPED: p Yes XNo (NOTE:MAXIMUM FREE-FALL DEPTH IS 301) <br /> Q SOIL BORING p HAND AUGER APPROX.BORING DEPTH 0046 )BOLTED TRAFFIC BOX or 1)STOVE PIPE <br /> I)OTHER: t]OTHER CONDUCTOR CASING PROPOSED? WO (if YES,list specifications here): <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,State Laws,and Rules <br /> and Regulaticru of the San Joaquin County. Homeowner or licensed agent's signature eertifles the following:I eerBly that in the performance of the work <br /> for which this permit IS Issued,I shell not employ persons subject to WORKERS'COIKPENSA•11ON Laws of t Wftmia." Contractor's hiring or sub- <br /> contracting signature cenrf,as the following:7 car*"in the performance of the work for which this permit is issued,i shall employ persons subject to <br /> YVORKERS'COMPENSAT/ONLaws of Cedfomia." <br /> :CAL4; ;CQV..... "'NIS • E COR'A l_C I? :...`}JR5`�N'AD.1QiFAN WVOJR. ,,,lltL'? 1RED�N <br /> signed x v TitWC-ompany DS¢r Z44%C, Lfnuirdze-0-, ,4 c <br /> Print Name G-. q e: - S-fe".Eggis <br /> - e <br /> DEPARTMENT USE ONLY '7 q <br /> Application Accepted By Date Issued I �o�I I C� Area r Z <br /> Grout Inspection By Dale Final Inspection By Data <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS= <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKS RECD BY DATE PERMIT t SERVICE REQUEST# INVOICE <br /> eD <br /> 1/18/2000 <br />