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J"J u3 L r FIFTH FLOOR PAGE 02 <br /> WELL PERMIT APPLICATION FORM UJJIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION ("PHS•EHD") <br /> ' 304 E. Weber, Third Floor, <br /> Stockton, CA., 95202 <br /> (209) 468.3450 <br /> ' NOWREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE is <br /> 5UED _} <br /> ,n 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 /> ,quin Courtly Development True Chapter 9 1115 3 and the Standards or San Joaquin County Public Health Services,Environmental Health Division <br /> LI-Location C E M e T F R Y LANE Cross Street NA R D 1 N Ct 5106�i 1 Q Assessors N To G— �` Z+p g_, T 4 Pa rcefp 14 -I0 0- L <br /> PROPERTY Owner CA' CL C-EM T� Address F0.8oK R3 Gdy�4bGItTOhJ zip�y`7o1 phone#_y6��EiC7 <br /> GR�GLr 17RtLLING4F MARIINc� <br /> ISIE;ultaril <br /> C57Contractor ES t NG ddress 95Q lit)W Rp , �' � ?0 SE ii City. GA ZIP94553 �S�TPhonetl 313- S it CC <br /> /Sub Contractor R M ( A V�CH Addresses R �H d M V 1 F CR City 6 B3 Lic# R 5 6 Phone# <br /> vS CoardmsLes n Tov r,s;rp Ran <br /> 8e Se,:t an <br /> ORIS TO BE P>`RFORMED —' <br /> NEW WELL I130RING(CPr, GEOPROBE HYDROAUNCH,HAND-AUGER,OTHER-) <br /> N SOIL BORING# L 7� U DESTRUCTION(choose type below) <br /> 'Of. ther 0 WELL# 0 OVER-BORE <br /> d PRESSURE GROUT <br /> OEMR <br /> OF WELL CONSTRUCTION TYPECONSTRUCTION SPECIFICATIONS <br /> MONITORING Q HOLLOW STEM DIA OF BOREHOLE I.9 rr MULTIPLE CASINGS?a YES ,NO WELL CASING DrA M R <br /> I <br /> q EXTRACTION A TYPE OF CASING CTION 0 AIR HAMMERIDRIVEN CASING THICKNESS t p STEEL a PVC a OTHER_ 1� A <br /> _ �� <br /> a MUD ROTARYDEPTH OF GROUT SEAL T D"10p Q AUGERS aHOSE <br /> li TREMIE TYPE TO 13f!USED <br /> WSPARGE 8 PUSH POINT 1� GROUT SEAL PUMPED f Yes a No (NOTE MAXIMUM FREE-FALL DEPTH IS 30) <br /> 1 SOIL BORING a HAND AUGER APPROX BORING DEPTH 100- FT a BOLTED TRAFFIC BOX or U STOVE PIPE <br /> OTHER CONDUCTOR CASING PROPOSED? N 0 (it YES, list specifications here) <br /> .OMMENTS <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS! <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances State Laws and Rules <br /> d Regurations of the San Joaquin County Homeowner or licensed agents signature certifies the following '7 certify that In the penlormance of the work <br /> Iff which this permit is issued l shall not employ persons subject to WORKMAN S COMPENSA77ON Laws of California, Contractor's hiring or sub <br /> iractmo sianziture cenifies the follow,na I certrfy then In the performance nif the work for which fhrs permit ss issued, 1 shall employ persons subject to <br /> ORKMAN S COMPENSATION Laws of Cakfomva- <br /> H A LIC LIST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS <br /> Inod x -7 <br /> IEE SITE MAP IN UNIT IV WORK PLAN DATED APRIL Z4 Zoc�e <br /> DEPARTMENT USE ONLY <br /> ppllcalion Accepted 6y. Date Issued ,area <br /> LttiI inspection By Rata Final Inspection By_ Date <br /> ruction inspection By_ Date <br /> OMMENTS I CONDITIONS a' <br /> NTING ONLY AID# FAC# <br /> D>=5 FEE INFO AAMOUNT REMITTED ,CHE SH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE <br /> v l�rl8 7S R 0 eOZT&S0 <br /> 'T IV-6/1/99/sign bkpg/MI <br />