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05/18/2000 14 56 2694683433 FIFTH FLOOR PAGE 04 <br /> $ <br /> -26-1 St-j5 a .4�dwm r K UM <br /> WELL PERMIT APPL-ICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES^ <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-IrHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 A1'�N 2 1 <br /> 2000 <br /> (20Sr 468-3449 IN ELff'- ;-! y;y <br /> NON-REFUNDAGLPPpwmiTmypRESIYEARFRQIU(DATEI$$1fEII P`ntl�l!r <br /> San-AppJ ataan is hereby made to 52n Joaquin County far a permit to Constructandlor rnStalt the worfi descnhed- Thrs a 86caLon rs made rn co R�r '^ <br /> San Joaquin County Oevefopment Title Chapter 9-111!;3 and the Standards of San.3oaqurn Cortnly Public Heath, Services Envirunm nc Meslth�p ren <br /> WELL Location LJ Crass street �1 Ass=c(S <br /> r e try p�So�Dq Par�alx a- t7J-UJ <br /> PROPERTY Owner t 0. S�C, c4�..k c*x?O � <br /> � � `�%+i71 p ISr�l Phone#2D- <br /> Contractor city ( tyLrd �729of pho.►e `77 - <br /> on5trltarttlSub Cantraaor <br /> tyy m <br /> ress � C y �U'; Phone:p-';70`f 2�-0- 3P-5— <br /> 'GIs <br /> 315GIS Coordinates X� Y TOwnSrsrp Range sect= <br /> WORK TO BE PERFORMED <br /> LYEW WELL 1 BORING(CPT,GEOFIROSE HYDROPUNCH HAND-AUGEp, OTHER-) <br /> Q SOIL SO a 13pESTFZUCT10P1(choose type be{ow} <br /> j/ <br /> LL iR 0 OVER-SORE <br /> *0thor Q PRESSURE GROUT <br /> COMMENTS <br /> rrps OF WELL, INSTALLATIONTYPEC0NSTRUCT10N SPECIFICATIONS <br /> ONiTOR1NG OLLOW STE1u1 DlA OF BOita=H4LE !f <br /> fl C"C1ON � _ MUL-nPLf:CASINGS-,Q YES �$o WELL CASING DLA. <br /> (j AIR HANMERJORiVEN CASING THICKNESS TYPE OF CASING Q STEEL 83--YC a OTHFR. <br /> (l R (I MUD ROTARY CEPTH OF GROUT SEAL TREMIE TYPE TO BE USED Q AUGERS gg <br /> Q A%Z SPARGE 0 PUSH POINT GROUT SEAL PUMPED '�'es No (NOTE- MAXIMUM FREE-FALL DEPTH ,3p') <br /> G SOIL BORING HAND AUGER APPROX BORING OEPTH Ol AOLTcD TRAFFIC BOX or g STOVE PIPE <br /> OTHER OTHER CONDUCTOR CASING PROPOSED7 ( If YES list sPecffica(rons here] <br /> COMMENTS � <br /> NO E. OFFSITE 80R4 OS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby comfy that I have preosred this applrc 2tron and that the work will to done in accordance wlttt San Joaquin County OrdrnanC� State Laws and Rules <br /> and Regulations of the San laaquu+County Homeowner or Ilcensed agenr's SSnature cert f`ies the lcac ,ng -C Gvafy tl.ar rn the performance of Iho work <br /> Clor which Chis Per,nit is issued l shelf not employ persons subje=to WORKERS'COMAF-NSATICW L.sws of Calffamla, Coniraaors hrnrrg ar sub- <br /> cantmczIN signature gerbties the foilowing 'I Cemfy Char in rM Pend' Tante of the Work for w**Ich this permlrls=Uod l mall emptoy Porsans subject to <br /> WORKERS AfPENSAF0N taws of C&hf=ja- <br /> APPLICANT MUST CALL <br /> TALL 48 HRS IN ADVANCE FOR ALL REQUIRED INS PEC NS/') <br /> srgnecl z r —� 4 V Vu I Tate ' f (� <br /> Oarc <br /> SEE SITE MAP 1N UNIT IV WORK PLAN DATED / A/, <br /> �PARTbtENT USE ONLY <br /> ippCrcatron Accepted By date 1s.;ued _ <br />;rout Inspection 8y Date Final irupeGmn 8y Date <br /> ieurucaon Ir�pecuon By O3tg <br /> OMMENTS!CONDITIONS <br /> - � <br /> ANG ONLY TlO# FAC# <br /> PE CODES FEE INFO AMOUNT RI:�,vTTF_Djj��TGC-K;*/ ASH RECEIVED SY GATE PEVL%11T)SERVICZ REQUEST NUMBER INVOICE <br /> Z7I -7 9 Gv s/r 0 <br /> C-57 UCE\TSr 1D CONTRA.CTOR ZbIUS-r SIGN'j_jCEXSi &'WOPI ERS' COM a-'4SA-n0N DELL 2, TTON <br />�ZT rV- 6/23/99/S+qn bkpg/jMZ <br />