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11/02/2000 THLi 12 12 FAX 916 777 1101 V W DRILLING INC X003 <br /> F KUl I GETT[ HC r HO;'E N13 3c--:3 <br /> S3 C12 2@0171 11 22F}l 1 � <br /> xWELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHL)) <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 Ir hereby made to Sar Joaquin County for a permit to comtruet and/or Inetali tha work aescnbed TI-is applrCatlon 13 made in comolianca witn <br /> San JosgUln County Development Title Chapter 9-1115 3 and the 9tanr;,rd,of San Joaquin County Fubtir IdoaRh services Envlronmantat Heath Divsio- <br /> Assessor' <br /> 4 N �7LtifeT6.1�zt gS-Z-z Parc*t* ,�`l•G. '!'S." Y]�v <br /> WELL I n—TiarlY/���i%`t _ Cross Street�-at•F ,'A City P -- <br /> '� zr tri aL Pnuni���� �1'7�-cF ? <br /> PROPERTY Ownor, �� -Y o� 7crc" 'Jgddres5�d l~ i✓. �4�r.en� f C t�y� p <br /> J' ' Address f%a 6ry! <br /> C-57 Cnntrartor <br /> �-7rt <br /> or /c � �dG ddress .?�� atm d�p� City G���Llc X-4 <br /> Consultantl Sutr CorltraCl C1 ,�� <br /> GIS Coordinates X <br /> Y Township Range Section <br /> WORK TO RE PERFORNtED <br /> DESTRUCT ON(chnase type te'ow) <br /> �lEW WELL I50AING(CPT GEOPROEJ= F�YORaPUNCH HAND-AUGER QTHER�1 p OVER-BORE <br /> 0 SAIL I;ORING# (]PRF,9,URE GROUT <br /> -PtWELL# <br /> 'Other _ <br /> commtNTS <br /> At <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> O,�IITORING OLLOW STEM DIA OF a0RCH0LE_� <br /> MIJLTIr'LE C.A.;111C�S�0 YES U WELL CASING DIA Z <br /> . HaMMERIOR <br /> ➢ AIr y 51 JD TYPE OF CASING n STEEL �&VC L3 OTHER <br /> Fa(YRACTtON QIR 11rEN CASING TNICKNESa__ r� G <br /> O VAIaOR �MUD ROTARY DEPTH OF GROUT SEAL J 7REMlE TYPE TO BE USE=D �AUGERS D�OCE <br /> p AIF,SPARGE ©PUS;t POINT GROUT SEAL A PROx BOFttNG DEPT of��I-Z-cl ' E- MAXIMUM FIC 9GX or a STOVE PIPE 0', <br /> 0 SOIL BORING Q HAND AUGER <br /> a OTHER 0 OTMRR CONDUCTOR CASING PROPOSED') (if YES list specifications here) <br /> COMMENTS <br /> NOTE- OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I heFaby cor4hr that I have prepared this appuCation and that the work will be aon�In accar�anre wltn San Joaquin c County t oil the pe StS16 ce o an@ Rules <br /> and tegulauvriS of the Sari Jaanum County Hecrreowrler or imensed agent's algnalure t,.ertifies the fallowing "1 CeRlfy filet in the performance ofth s work <br /> for which this permit Is Issued, I shalf not employ persons"blec!t�WORKJ=RS'COMPFNSA nON Laws of Carhfornra" Contractor's hiring 4 <br /> contractin¢t lgnaLve CertifiaS the following `(Certify filar in the per:7rmance of the work rrjr wh,rJr this pc►mrt is I.�sued,I shall employ persons subject to <br /> WOR)<99S'COMPENSATION l aws of C8100MIA" <br /> THE APPLI NT MUST CALL 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS <br /> Y s.urtdL Ua'e J/ 2- <br /> Signed <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED- <br /> DEPARTMENT USE ONLY O J <br /> ��-�. .�',)y►/� Date issued Arra , <br /> Applicabon Acoeptod t3y Final Inspection By bate�— <br /> Grout Inspection Sy - Oates <br /> Destruction InspsClien By Da c <br /> COMMCNTS I CONDITIONS <br /> I <br /> ACCOUNTN'NG ONLY AID# c <br /> PE DODEG FEE INFO AMOUNT REMITTED CHECK# REC'D By DATE PERMIT 1 SERVICE Rt4UEST# INVOICE <br /> Cr57I.xCE�ISIJD CON-I:'1�ACT0�'M�3STCENSE.&:WQR��RS'COMP�N5Al101� Y�LGLA,R�`�ON <br /> UNYT IV-6/231/99/sign 6kp9JM1 <br /> 11/02/2000 TNT 12 11 [Th/ELL \I1 oITA] 0,0U f <br /> 3 <br />