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11/03/2003 14 50 2094583433 FIFTH FLOOR PAGE 02 <br /> �, , �- WELL PERMIT APPLICATION EVRM W UNIT IV <br /> EME1 <br /> NOV 1 6 2001 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION ("PHS-EHD") <br /> ENVI';'D"!0EW HEAUN 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> PERIVItT,SF=RR4ICES (209) 468-3450 <br /> NON-REFUNDAIBLE PERMIT EXPIRES 1 YEAR F M DATA:IS UED <br /> Application is hereby made to San Joaqutn County for a permit to Construct and/or install the worst described This application is made in compliance with <br /> San Joaquin County Development Title Chapter 9-1115 3 and the Standards of San Joaquin County Public Health SErvwes Environmental Health Divisiort <br />� Assessor's WELL Location-11%14 E. q u Hro AVg, cross street 4 S UTA --City Sfio t kto h z,p��?D Parcel# l <br /> PROPERTY Owner $q K �o v t Co uh t Address 1 7x E. Scotts A v$, city.Sto c( to In 9 S 20S Pttone# 99 19 <br /> C 57 Contractor MItCti�II D%.Il i'49 Address 1061 Mil ZZ,0 W4 CkyCo14rd05 Zip Lim( -�}�.Phonera 531- 8 <br /> Tos�pk.�4M49e r0>< Box 669 { 916 <br /> Consultant/Sub Contractor ilk V4 2 PKV V'o1A Mt 1. Address_R 4K��D 11%4f+-et•4. -City 9 S 6 Ljc0 SSG Phone#l5 4-3 S o_ <br /> GIS Coordinates X ,Y Township Rangi! Section <br /> WORK TO BE PERFORMED <br /> 6 NEW WELL./BORING(CPT.GEOPROBE,HYDROPUNCH,HAND AUGER,OTHER*) []DESTRUCTION(choose type below) <br /> a SOIL BORING 0_ C PRE SU RE <br /> WELL <br /> W" �PRESSURE GROUT <br /> •Other <br /> COMMENTS One Q -Site m0wiltswtlt Well <br /> TYPELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS 2 IH <br /> MONITORING HOLLOW STEM DCA OF BOREHOLE -IN C H MULTIPLE CASINGS?Q YES 5 NO WELL CASING DIA <br /> TRACTION I>AIR HAMMER/DRIVEN CASING THICKNESS$4H 0 TYPE OF CASING 0 STEEL 6 PVC D OTHER, <br /> iPOR <br /> Il MUD ROTARY DEPTH OF GROUT SEAL I-F Ii:_G'r TREMIE TYPE TO BE USED 6 AUGERS CHOSE <br /> D AIR SPARGE (I PUSH POINT GROUT SEAL PUMPED' I Yes D No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> n <br /> HAND AUGER APPROX.BORING DEPTH S'FI=E T V BOLTED TRAFFIC BOX or D STOVE PIPE <br /> 1)SOIL BORING <br /> CONDUCTOR CASING PROPOSED? NO (if YES,tist specifications here) <br /> D OTHER <br /> COMMENTS <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS! <br /> I hereby certify that I have prepared this apptioaUon and that the work wIN be done in accord les with Sang q Cerufy tthY <br /> Ordinances lt performance a f the work s <br /> and Regulations of the San Joaquin County Homeowner or licensed agent s signattire certifies the foltowuig Y ws of _ <br /> for which fhis permit is issued.l shall not einployperxons 31*90t 10 SCOMPENSATION ltisissued,/shall employ A��^s 5ublecf tv Sub <br /> contracting signature certifies the i9ftwing 'l carer/Y that in the peAWM <br /> WORKMANSCOMPENSATION Lawsoff e% 8 8 IN ADVANC FOR AL REQUIRED INS7�TIO S_ <br /> HE PLIC r dr <br /> Title Date <br /> Signed z <br /> SEE SITE MAP IN UNI IV WORK TED <br /> SEE <br /> DEPARTMENT USE <br /> Date tssued��2.6'0/ Area� <br /> Apphcabon Accepted BY Ffna1 inspection ay Dater-- <br /> Grout inspection BY Date <br /> Destruction Inspection BY Date <br /> COMMENTS l CONDITIONS- <br /> FAC# <br /> COUNTING ONLY AIDdf <br /> Erz INFO AMOUNT REMITTED CHECKWCASH RECEIVED BY DATE PE (rtSfiRyICErREQUEST NUMBER tNVOtCE <br /> PE CODES F <br /> Z/1-6 Ah< <br />' VNTT TV-6/1/99/sign bkpg/MI <br />