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X4/2000 09: 07 2094683433 FIFTH FLOOR PAGE 153 <br /> WELL PERMIT APPLICATION FORM UNIT Iv <br /> i SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD <br /> N t'"5 304 E. Weber, Third Floor; Stockton, CA.. 95202 <br /> (�u» ° (209) 468-3449 <br /> s l�P s;k a . <br /> NON-REFUNDABLE PERMIT EXPIRES'I YEAR FRO DAT SSUED <br /> Application Is hereby made to San Joaquin County for a permit to Construct and/or install the work described. This application is mensalade compliance DviSi with San <br /> Joaquin County Develop/m�ennt Tiitie.C,hhapp�ter 9.1�115.3/and.ths Standards of San Joaquin County Public Health ervices.Environm Pa�ssolf Dlvis <br /> 37 F// rl�. Gross Saee 414 FIi9 Zip //�s�, <br /> WELL Location �11 /�„^ %ke�/� C Uyp9�Phone# <br /> PROPERTY Owner ,"� ' wJra' Address `/W g <br /> Ci hone#R <br /> C-57 Contractor Address Ci (7 _�Q0 <br /> Ci e� Phone#✓ <br /> Consultant/Sub Contractor Address 00!'rn � A0 <br /> GIS Coordinates:X ,Y ,Township_ <br /> ✓_Range Section. <br /> WORK TO BE PERFORMED: NI9 <br /> - - 0 DESTRUCTION(Choosetypebelow) <br /> O NEW WELL/BORING(GPTI feEOPROBE,H ROP CH HAN - Urj R OTHERI) OVER-BORE <br /> j ,K SOIL BORING. _ r B PRESSURE GROUT <br /> 0 WELL# <br /> 'Other: <br /> y <br /> j COMMENTS: <br /> II TYPE OF WELL INSTALLATION TY E CONSTRUCTIQ14 SPECIFICATIONS <br /> CASING DIA-'— <br /> O MON17ORING O HOLLOW STE DIA.OF BOREHOLE MULTnIPPLECASINGS?ING; Q STEEL 017 PVCLLO OTHERI. <br /> O EXTRACTION n AIR HANIME RIVEN CASING THICKNESS <br /> n VAPOR, - 0 MUD ROTAR DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: n AUGERS OHOSE <br /> 0 AIR SPARGE O PUSH POIN GROUT SEAL PUMPED; 0 Yes p No (NOTE: MAXIMUM UMTRAF�R e�x ALLor 0DEPTHSGIS 30') <br /> p SOIL BORING 0 HAND AUG R IPE <br /> APPROX.BORING DEPTH 0 <br /> n OTHER!—O OTHER CONDUCTOR CASING FFiOPOSEO? (if YES.list specifications here): <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMIT <br /> I hereby certify that I have prepared this appliCation and phot the vrork will be done in eCCordan00 with San Joaquin County Ordinances,Sbte Laws,and Rules <br /> �. and Regulations of the San Joaquin County- Homeowner or licensed agent's signature certlBes the following:'7 certify that fn the periom+anre M the work <br /> forwhich this con tract hisnature rlif Is gss the shellng t'efn <br /> f 09p+6YY thatsn Etre performance o!lh�Srk ro which Nis pe Kis issued,hl shall employ pe sons sub ect to b <br /> WORKERS'COMPENSATION Laws Of California.' <br /> NR IV INSPECTOR 48 WORKCiG HRS IN ADVANCE FOR ALL RE�RE��CTIONS <br /> fSigned x TiBa Company <br /> Print Name / <br /> 4o/ sr� yi. <br /> LC2v0'35i <br /> SITE FILE ADDRESSM/ORK PLAN DAT <br /> L-1'2-052) p S <br /> DEPART-cm '0 'Y CC> Area U 7 5-- <br /> Application Accepted By & Final Inspection By Oate <br /> i Grout Inspection By Date_ <br /> Destruction Inspection By Date <br /> 1�7 Earp �rl� ¢ L <br /> COMMENTS lCONDTf10NS:r- 1 � <br /> ACCOUNTING ONLY: AID# <br /> Pfi COOE3 FEE INFO - AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> 3sa S9 ' <br /> 377 9G& Co I j'Z 0- SBA 622a /53 <br /> C_57 exp,WC/waiver C-57 Letter of Authorization to sign permit_ Encroachment doc(s). 5/17/00 <br />