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09/27/2000 15 07 2094583433 FIFTH FLDOR PAGE 02 <br /> Rect lid Isar-03-00 12 59pm from CCITT G3 A0VA SCIENCE Page 2 <br /> -tai- 0p 1 02PIA a=ROht p 2 <br /> -'c <br /> WELL PERMIT APPLICATION FORM UNIT IV << - <br /> Pij <br /> . 56 <br /> < < SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> in ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> - 304 E Weber, Third door, Stockton, CA , 96202 <br /> (209) 468-3449 <br /> NCN-REFUb!C)A0LE PERMIT EXPIRES 1 YEAR FROM DA):E IS9U56 <br /> AaPbcauon is hEre'Sy made 10 San Joaquin Soupy for S Per--"...eons -d and/or rnli2g the+wry de:utbtd Tn1>t zppll�a,lan Ir nadc re,Coneplianer with <br /> $an Joags in Count/Dcvolopmen Trdc Chapter F I tS:and the Standafft e.San Jo2quin Co.tnty Public hearth Scm"r Envi anrnental Healt-I Divi,of <br />� .� a,.' Assexcor s <br /> WELL LDutforn 5 W G omst:Street .I r.-y X&Il, SCI y_/� _ZrP.9--336 r-3ec gr_2L3; <br /> PROPERTY0wrer Z4r1,1z= Si" ACoreec .cl.LCr��., �d Crty1'1ar2_ Z1;Y!EPhonE9Xz <br /> GsyCon'rsrer tSfi 41-n Address 950 Haut, C,Ivff-L�­-21 ZIP21'J'�573Licc-ff!;&!i 121one+l (9. s 3fY-5,5�'Cre <br /> Rneult�n Sut CorlVgcM7R4k er-ea-� U ,rrl';" Cr1b.'04r7V_!)'. U[= PAO".! «.LS ` -Y -1 <br /> Gt5 Cot're.natrs K Y Y Tovr�sMip Fargo 56 5� <br /> W2RK TO 5E PE RFORME0 " <br /> ),<4-mW WrLL 1 COIt a(CPT GEOPROCr HYDROPUNC�- hANC AIJ3ER OTH`cR j p OES7ikl,CTICN(choose ty F-Mloy <br /> SOIL EflRIN3 k-S.P7--,r &,.,I t'JCA7'—Z- 0 OVER 9'J;Zc <br /> g9 Kc'Lt.a—M� f -Y, Q PRESSURC GQnUT <br /> 'tattier <br /> COMMENTS <br /> TVP;:OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 1KA0MTORINC )<tiOLLOW STEM CIA Of EOF;EHOLf rr IMULTI'LE CASINGS?U YES , 7 WELL CASING CIA r <br /> 0 EXTRACTION 0AIR 1-1444'FUOR1VEN CA5tNG THICKNESS 51-4' o TYPE CF CASING p STEE- e:FVC U OTHER <br /> p VAPOR p MUO ROTAR`r DEPTH OF GROUT SEAL �� TREMIE TYPE TO EE USED SeAUGERS 0HOSEE <br /> p N4 SPARG: p PUSH POINT GROUT SEAL PU&IPEO Q Yes J{iJo (NOTE MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL SOPING 0 HAND AUSER Ae'PROX BORfNG DaPT H 15- j1-!6'0LTED TryAF-lC BON Dr a$TO VE PIPE <br /> p OTHER_a OTHER__ CONDUCTOR CASING PRQPOSE07 0 f tr"S tit srectfrcaltonc hare/ <br /> C0114KENT5 <br /> NOTE: OPPSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby certty th.t I have prQpv d INS opoitcatton and IhM the nrorft wrri be d6no rn eetwldrnee with San Joaquin County Ordinances Suit U iwi< and Pie% <br /> and RaQulattens of the San Janavrn County t4orne9W"t4r or rteenaed apcnt'e slgnalure eerti5os thin following "f cerflly that in Mc perfoimanee of ttte work <br /> for which this pernlf 1s Issued,f sAallnot employ peraena aubfect to WOf?KER5'COMPENSATION Laws of Cahnr <br /> lornie" Coracioeit hlnrg or of b- <br /> contractuV stpnFture tenrlt9 the following I cetldy that In the pertormjAc*of tho work for Wh/ah thls permh Is smued f rh#4 amploypersons dtrbrcV to <br /> INORKERS COtIPENSATfONLewd olCiflfanra <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HR.6 IN ADVANCE FOR ALL REQUIRED INSPECTION$ <br /> Scmad �t�i l'[���� T-ttelComecny I e- 1"f/a-*l At e-, { <br /> Print Marne 1-+aX y tJ.->`c+ ' C Z OUc !t'Z*'!OD <br /> �s�l=.SLT9- AP�IN ter#IT, V;_o_I <br /> rr <br /> ��� � j� DEPARTMENT USE ONLY <br /> AVPdcauonAtxepted Eyawsl,4L" Oct Issued !zO <br /> Clout Incoecibon By Date Fin.'JI InapeUlon By Date <br /> Ors-,rudfort Insp•tLon Ey Dote <br /> COMMENTS/COJUDIT1ONS <br /> IF <br /> ACCOUNTINIG ONLY <br /> e _ <br /> PE CODES FEE INFO AMOUNT REMITTED I CVECK 0 RECD BY OATS PERMIT/SERVICE RtiCIVEST 9 INVOICE <br /> 3S4 Z7�"f Z Agg ae 2112"4 <br />