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03/06/2002 10 15 2094683433 FIFTH FLOOR PAGE 02 <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOA UIN COUNTY PUBLIC HEALTH SERVICES <br /> Q O <br /> ENVIRONMENTAL HEALTH DIVISION ("PHS-EI-113") <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3450 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 De"lopment Title,Chapter 9-1115 3 and the Standards of San Joaquin County Public Health Services Environmental Health Division <br /> G F-K&T F-R.( Assessor s <br /> WELILLocation H A R 4 k N 4 WA ( Cross Street LANE_ —city ST 0 G 6TO M Zip 9 5 7 01 Partes# <br /> SAN JOAO,Vl Z09) <br /> PROPERTYOwrier CAT4QLK GEME.TER`f_Address P013 113} Cny5Tt)0TON Z,p35101 Phoney 6 V6107, <br /> MtjCrlt=Lt- INCH (916) <br /> C-57Contra4:tq DLk.ILLINCr LNV, Address 10641 111111.4110 WAY City 00V 425G-0 L,ri161261*Phone0 SS2-9559 <br /> ItANrH0 R,G-. 49th) <br /> Consultant/Sub Contractor SCA M A-FE: ENV, Address A O B 6 119 City MV It I kTA Lic# 5 B 5� Phone# 35 -3z 5 a <br /> GIS Coordinates k I Y Township Range section <br /> WORK TO BE PERFORMED <br /> NEW WELL 1 BORING(CPT GEOPR08E,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> 0 SOIL BORING# 0 OVER BORE <br /> WELL N W^ W- FA PRESSURE GROUT <br /> "Other <br /> COMMENTS <br /> TYPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br /> I MONITORING I HOLLOW STEM DIA OF BOREHOLEj0_-j_14C14 MULTIPLE CASINGSI 0 YES 1 NO WELL CASING DIA x-I� <br /> 01FR <br /> TRACTION 0 AIR HAMMER/DMVEN CASING THICKNESS SCI; Ito TYPE OF CASING Q STEEL j PVC R OTHER <br /> POR 0 MUD ROTARY DEPTH OF GROUT SEAL 26 f 5( TREMIE TYPE TO BE USED I AUGERS BHOSE <br /> SPARGE 0 PUSH POINT GROUT SEAL PUMPED 0 Yes l No (NOTE. MAXIMUM FREE-FALL DEPTH 1S 301 <br /> 0 SOIL BORING If HAND AUGER APPROX BORING DEPTH 5a 1 13 _ __I BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER CONDUCTOR CASING PROPOSED? NO (if YES,lis(speCifiCalions here) 14A <br /> COMMENTS MW-gh ANO MW -66 To BE A WELL CLUSTER , Mw-oA To BE 5f? r DPEp <br /> MW-81) TO 8� 13 r DFtP. <br /> NOTE: OFFSITE 13ORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITSI <br /> I hereby Certlfy that I have prepared this application and that the work will be done in accordance w$h San Joaquin County Ordinances Stale Laws,and Rules <br /> and Regulations of the San Joaquin County Homeowner or licensed agents signature certifies the following f certify that in the performance of the work <br /> for which this permit rs Issued,/shall not employ persons subject to WORKMAN'S COMPENSATION Laws of California" Contractor's hiring Or sub- <br /> contracting signature certifies the following `1 Certify that in the performenCe of the work for which this permit is issued I shall employ persons Sublecl Io <br /> WORKMAN S COMPENSATION laws of California <br /> E A LICANT U T ALL 4 RS IN ADVANCE FOR NALL 'REQUIRED INSPECTIO L 5 <br /> ti Tdle <br /> � I�SL RF�� Date �. <br /> Signed)(4 <br /> SEE SITE MAP IN UNIT I WORKPLAN DATED 61101011 <br /> DEPARTMENT USE ONLY <br /> Date Issued <br /> Appboation Accepted By a -� <br /> Grout Inspection By Date Final Inspection By <br /> DestruoWn inspection By Date <br /> COMMEriT$!CONDITIONS �/nfi�f+d-Yt..Q <br /> FAC# <br /> COUNTING ONLY AID# <br /> CODES I FEE INFO AMOUNT REMITTED CH CASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE <br /> 3, � �5= z d o Z`2o <br /> UNIT IV-6/1/99!sign bkpg/MI <br />