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11/28/2000 11 39 2094683433 FIFTH FLOOR PAGE 03 <br /> 4) #, <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) � <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <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 desanbed Thls application Is made in oomphance With San <br /> Joaquin County Development Title Chapter 9-1115 3 and the Standards of San Joaquin County Public Health Services Environmental Health Division <br /> Assessor's <br /> WELL Location/Z-'Z;> LL_) Cross Street /VC)/'�1a Zip S3 Parcel#c�t7 07C) !ej <br /> PROPERTY Owner M,Wic Address - CIry1"{a+,-6tcn Zip IS32LPhone0 aP4_-Ta3-37y.c- <br /> C-57 ContractorGag4 , Address_2�a fro ux A as cA <br /> � l� 9� 1rQ <br /> Consultant 1 Sub Contractor�a rr,Lrj'c, F'.,v,n,,=.e^'14ddrass 1/Y U 4 t�1, S+ Crty 2,LC 6 Lic# Phone# SLC;5!.�C-C <br /> CIS Coordinates X Y Township Range Section <br /> WOR <br /> K TO BE PERFORMED <br /> "EW WELL 14jORIN CPT, OP B HYDROPUNCH,HAND-AUGER,OTHER-) Q DESTPUGTiON(choose type below) <br /> SOIL 13ORING# ' - B- S6-r, s a'Co p OVER-BORE <br /> Q WELLbtl - " Q PRESSURE GROUT <br /> 'Other _ A _ - r _ <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING C HOLLOW STEM DIA OF BOREHOLE_a rL MULTIPLE CASINGV 0 YES ]]NO WELL CASING OIA <br /> 0 EXTRACTION []AIR HAMMERIORIVEN CASINGTHICKNESS A-1A. TYPF�OF CASING O STEEL Q PVC []OTHER— <br /> Q VAPOR []MUD ROTARY DEPTH OF GROUT SEAL �,� y,_TREMIE TYPE TO BE USED Q AUGERS 0;0S <br /> p AIR SPARGE PUSH POINT GROUT SEAL.PUMPED d Yes n N (NOTE MAXIMUM FREE-FALL DEPTH IS 30') <br /> VOIL BORING n HAND AUGER APPROX BORING DEPTH 7_s _0 BOLTED TRAFFIC BOX or p STOVE PIPE <br /> Q OTHER OTHERC-, rr,},_e—CONDUCTOR CASING PROPOSED?-A//A—(if YES-list speGrcations here) <br /> COMMENTS <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I 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 /> and Regulations of the San Joaquin County Homeowner or licensed agent's signature certifies the following 111 cerrlfy that in the performance of the work <br /> forwhlch this permit is issued,1 shalt not employ persons subject to WORKERS,COMPENSATION Laws of California' Contractor's hiring or sub- <br /> contracting signature certifies the following 7 certify that in the performance of the work lion which this permit is rssued,i shall employ persons subject to <br /> WORKERS'COMPENSATION Laws ofCahfv,rra " <br /> P L THE UN , OR <br /> IT 1V NSPP A,WQRX, 1Ng, 11FS �NAbJVI_NCE FOR ALL REQUIRED.INSPECTIONS <br /> Signed x l��) - Title/Company <br /> Pint Name r 44_- V Date <br /> 1' DEPARTMENT USE ONLY <br /> Application Accepted By Date Issued <br /> Grout Inspection By Oate Final Inspection By Date <br /> Destruction Inspection Sy Date <br /> COMMENTS!CONDITIONS <br /> 1 <br /> ACCOUNTING ONLY AID# _ - <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEE# EINVOICE <br /> SRO <br /> 1/18/_1000 <br />