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09/27/2000 15:07 2094683433 FIFTH FLOOR PAGE 02 <br /> Redei4d Mar-03-00 12'59pm from CCITT G3 AQUA SCIENCE page 2 <br /> -fd3- p 1 -02PfA FRcm P.2 <br /> • _ � Ill.rii.?'� <br /> 1, WELL PERMIT APPLICATION FORM <br /> 00 S1-12PH I: 56 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SE=RVICES <br /> LZ <br /> ENVIRONMENTAL HEALTH 01VISION (PHS-EHO) <br /> 304a E. Weber, Third Floor, Stockton, CA., 9620,E <br /> (209) 468-3449 , <br /> NOR-RIEFUNDA13LEPERMIT EXP]IR15S 1 YEAR FROM DATE rS3uED I <br /> Apph=Tion Is hi!rt!,iy mode to Son Joaghla r^ouaty IV a permit=eonstr-_d and/or inst21 the v� &de-_crib ed. TSIs applfca;Ian Is nsde ilj C4wP1ianu with <br /> San Joaquin Courtly Devoropmen:Tjdc.Chapter F-1:15.3 and the S12nd2rd9 o•San Jo�-gvin C6ordy PubIIC Htslth Servic86,Fnvironmemsi Heal OlvtSton. <br /> I WELL Loc-adon / r l Assefcar'S <br /> l S f W.�Stc+orf-Gr 14. /Cd'_Cross Street-T Y GV+rs clay_/!C z,9 L�Fs ceA►_�.L -34-Or <br />` PROPERTYUXrer Z4#nArrr Acrcre66305A/14(n%f,j&A City tin --Zia , PhomEt <br /> C-sTC,)ntr4e:w ddress 75a Noca�, City zip YS5 GcslB lG P:on<X �px5)3r3. crQ <br /> cneuhan 5ut_Go!1Lr�c;:1�A,�, - ??-e..'i!A u" ;rrf.S.d CI>u_Dtn✓:111 Lit=�anorx�,�9.Z� �p -535/ <br /> GI$Cocr6nams:X y Y i0�1 Shlp i�angn SEc,;o� <br /> WORK TO 6E PE RFORMEO ?E' <br /> K4-W V1ELL;EORIrti{CPT.GEOPROEE,kYDROPJNCF,h'AND-AUGER,,OTHERS D 0557 kvCTIOh{cCosse typ; <br /> �q SOIL EORIN3 f_6,127--i ��..I_ S 7�J�Z Q OVER•B0�3 <br /> yR WcLL S. 1+l T? ! f'T✓ l ,l-S Q PRE55URE GROUT <br /> •Otyer; <br /> COMMENTS: <br /> TYP%OF WELL t+STALLATION TYPE CONSTRUCTION SPECIE C-TIONS <br /> j1c90NlTORINC 7<1'IOLLOW STEM OIA"OF EOREHOLE rr MULTIPLE CASIN(35?D YES 1]110 WELL CASING DIA r <br /> D EXTFI.CTION PAIR CASIK^;THICKNESS 544- O TYPE OF CAS NG' Q 5T_E: WPVC g OTHER: <br /> D VAPOR 0 nlua ROTARY DEPTH OF GROUT SEALTF.EMIE TYPE TO BE USED; jk-AUGERS 8r,C5E <br /> a okfR SPARGE 11 PUSH POtNT GROUT SEAL PUMPED. U Yes jyl4o (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) � <br /> {3 SOIL E0P11413 D HAND AUGER APPROX.BORING DEPTH /5` 1�60LTEO TRAFFIC t30k or U STOVE PIP"c <br /> I}OTKER: p OTHER CONDUCTOR CASING PROPOSED? e I Ir YES,W s;eCkl"ICAlona hare):,,-„ _ <br /> ' COMMENTS: 14125,0 v 44,1 <br /> NOTE. OFFSITE SORINGS'REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> thereby cGRiy th:t[havv prap:rrd this epalcation and the. the work wit bo d000 in acaordsme with San Joaquln County Ordinances.Slue Laws,and Ruies <br /> s"RaQulaaont 9 the Szn Joagvin County. Homeowner or Iieansed apent'e slgn=lure ccrci5os tha(ollowing; "I certify th-7t in Me pelfom mca of the work <br /> for whrch this pern7ji Is issued,1 Miall not ernpfoy percena aubjest to WORKERS'COIdPENSArION Laws of Calilor:)4," Contractor r hlrinc or <br /> contracCLM SiQn!ture cerlifies the tollowlW'I cot9y thaf In tea p¢rTormence of rho v.01:forttfth this permlr is issued.I;haR cmpfoyptnons s4rb,ICCf ro <br /> 11410'.KERS'COMPENSATiOh'Laws o7Ca1Xxwo." <br /> �CALL'THt UNIT IV INSPECTOR 48 WORKING HRS IN ADVANCE'FOR-ALL REQUIRED INSPECTIONS. _ <br /> Print Name !`t1L!' W� r�r f� Out <br /> SESITE�.NA . '� <br /> 0EPA RTMENT USE oNLy Q 1 ? <br /> Appucatlon Accepted By 02%Issuad r 0 Arc (/ f�1) <br /> trout Inspadion By Date final Inspcctkon By nate <br /> ot-lZuetlah Inspeelioh Ey Date <br /> COMMENTS <br /> Sr <br /> ACCOUNTING ONLY: AIO. <br /> PE CODES FEE 140 AMOUNT REMITTED CHECK a REC'D BY CIATE PERMIT/SERVICE REOUEST a INVOKE <br /> 3,1-0 Y-f -L kw——L- o <br />