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tF <br /> WELL PERMIT APPLICAW" U tui <br /> '�DJV RONiPENIAL HEALTH <br /> SAN JOAQUIN COUNTY PUBLIC Hf?XEYiT6'1fiiWCF& !J <br /> ENVIRONMENTAL HEALTH QIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 rM5 30 _164W4 <br /> (209) 488-3449 W A%0j r-- �tt,s <br /> NON-REFUNDA13LE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> Applicatlon is hereby made to San Joaquin County for a permit to con6trad arndlor Install the work described This application is made in compliance with <br /> San Joaquin County Davelopmeet Frt1e Chapter 9-1115 3 and the Standard of Sart Joaquin County Public Health Services,Environmental Health Division <br /> 4 y G Assessar s <br /> WELL Location rVST i Cross Street cityOt�t>�l) Ip_1'12[7 --Parcel# <br /> PROPERTY Owner L Address��2 �,Artt15 -� -- City ti Zip_7�i3�-Phone11567 Z6"! i <br /> C-37 Contractof.�Al_ T rU8� _AddressT� I1fi?l l7U 1 r7 _ Grt�{ �D Zip�_t_{d1 �f Phon 3 �j D - �11t 1 <br /> Consultant!Sub Contractor r :;;L ddress � C_ +114i _ctt6da t_ if -�— Pban 20 `1 8-130 <br /> GIS Coordinates X 'y Township Range Section <br /> WORK TO Ag PERFORMED <br /> WELL 1 BORING(CP OFR YDROPUNCH,RANO-AUGER,OTHER-) (I DESTRUCTION(choose type below) <br /> R S BORING i< Q OVER-BORE <br /> 1]WELL iY ID PRESSURE GROUT <br /> .Othaf <br /> COMMENTS tj 19 Wggjjj,,A <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING d HOLLOW STEM DtA OF BoREHOLEZ MULTIPLE CASINGS?0 YES 0 NO WELL CASING D1A <br /> Q EXTRACTION p AIR HAMMEPJDRIVEN CASING THICKNESS TYPE OF CASING D STEEL 0 PVC 1)OTHER <br /> (1VAPOR ;�P <br /> Ui7 ROTARY t7EPT1 f saF GRQUT SERL 1 TREMIE TYPE TO BE USED iI AUGERS (]HOSE <br /> AIR SPARGE J`SH POINT GROUT SEAL PUMPED p Yes (NOTE MAXIMUM FREE-FALL DEPTH IS 30') <br /> (I SOIL BORING (I HAND AUGER APPROX BORING OEPTFf 2 n n aoLTEI7 TRAFFIC BOX or [I STOVE PIPE <br /> 11 OTHER �OTHER CONDUCTOR CASING PRQPOSED7_ _ (rf YES,list specifications here) <br /> COMMENTS 4 <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hertby certify that I have prepared this appticatlan and that the work wail be done In accordance with San Joaquin County JOrdmances,State Laws,arid Rules <br /> and Rcgulationa of the Sen Joaquin County Harmawner or licensed agent a signature cartifles the following "I esrL*fy that in the pertiormance of the work <br /> for which this perm#is issued t strait trot emooypersons subject to WORKERS'COMPENSATION Laws of Cafftlorrrla." Contradat's hlring or sub- <br /> contracting agnature oertliles the following 't oer ft Nrstin the performance of the work for which Iters permit is Issued I shall employ perwas subject to <br /> MRKERS COMP SATfOM taws of Carikinis. <br /> f! 011 IWQRJW" �r � �sVr <br /> Signedx TrtielCompany Klet "*"!z �U~rL1 �e�Ct1 r <br /> I <br /> Print Name r Date <br /> DEPARTMENT USE ONLY <br /> Application Accepted BY -_-_Date Issued_ 0 Area�Y <br /> Grout Inspection By Oate 'Final Inspection By pate <br /> Llestruchon Inspedion By {fate <br /> COMMENTS I CONDITIONS <br /> ACCOUNTING ONLY AIO# <br /> PE CODES FEE INFO AMOUNT REMITTED CMECK ti RECD BY I DATE PERMIT I SERVICE REQUEST k INVOICE <br /> 3�OIZoo/ -2(aSR# O <br /> 1118/ZU00 <br /> n� 7C A7 0007/07/bQ <br />