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11/02/2000 THU 12 11 F-C 916 777 1101 N of DRILLING INC X1002 <br /> i <br /> FhCfi GET LER-F,AN LNZ =r41>NL NO `J1 32 -"7i 1 ?11+11 F' <br /> 14 u <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 ExI lKES 1 YEAR FROM DATE ISSUCD Hance wleh <br /> Application is naretay made to$an Jnaqurn Ceunty frr a permit to car s+ruct andfor install the work de~cubed ThEs 8pplseatrnn r,mads M comp <br /> San Joa:ut�County d6veloprrirf5t TR a Cnact.r 9-1 15:�an i the 5ta7dards of 5a�Jaaaurn County public F{AaRh ScrvtGEs, E^�l Ass ssa l�ealt �-ci <br /> �.�7�- /�/�✓�L. �' Grass Str•.et L.��.�r +1Q+ city �10'�"ki ZIP :rz a4 Pan.el� <br /> WELL Locat+on ---' <br /> rf� 74�d Glrylrr4.�6tz-+f Zlp prc^se�F <br /> PROPERTY Owner r' o!- � Aadros6 I! <br /> C-STGOntrartor Addrzss ts�G}c J" Gtty 12r- <br /> rF,-c Ci rn r �,is.-+e <br /> �+ axaa�A Phone# <br /> Consuit]nt I sCommc <br /> !sub Cctor�-7'r'r ce ��ra i 2--e- nddress% n• ,d ZeC}- Ctty Llcta G <br /> GIS Gao+dl-ares X Y <br /> Town%hlp Range Sect ori <br /> WORK 70 8E PERYORM6D <br /> n DFESTRUCTION(chcobc Lypc below) <br /> j W WELL f BORING(CPT,GEOPROSE, HYDROPUNCH HAND-AUGER OTHER•1 a OVER-BORE <br /> p SOIL BORING rr f � v- �f.J,`p4_ p PRESSURE TROUT <br /> �yvELL# G!1 u- <br /> 'Othar <br /> COMMEN-S eortSTRUCTION SF'reCIF1CATICt�S <br /> TYPE OF WELL INSTALLATION TYPE �� ,, /� <br /> HOLLOW STEM 01A OF BoRr=HOLF A MULTIPLE rA�INGS�fl PES O WELL GA51NC;nal T <br /> ON11ORING Xtw 9VI TYPE OF CASING U STEFI �Vy ❑4THF-R <br /> 0 FXTRACTION 0 AIR HAMMERtDRIVEN up.P uvG THICKNESS��a{� TIZEMIE 7YPC TO 13E USED p AUGERS 4OSE <br /> �APOR Q MUD ROTARY DEPTH OF:GROUT SEAL <br /> IR SPARGE PUSrA POINT GRULJT SEAL PUMPED Ayes [!Na (NOTE MAXIMUM FREC-r ALL DEPTH 13tl'} <br /> rpt APPROX BorlNG DEPTH ' cc �� OLTEd TRAFFIC BOX or [�STOV[ PIPE <br /> U SOIL BCR`IG p HARD AUGEF. CONOUr*TOR CASING pRor'oSEP? (r`YES liet gpeaf+cmt,cns neve) <br /> 0 OTHER x.----13 OTHER <br /> O <br /> 077k� Cc/ T. 7 t <br /> COMMENYS -:--' /tlGl r ���•i/z G7- Z , <br /> NOTE OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> —9116�A-Ies <br /> L heretly certify that t have prepared thrs appllGallOn wrdcr ur 4tCensEi agentes�9natune in ere cert fiascwdancethet as winga9l certify ih In County�orstrHr Parfarma ce of the work <br /> and Ro�ulalznn5 of the San Joaqutrt Coun'y <br /> fpr which this pe►mft rs rssued t shall nut employ Persons subject to WoRHERS�COhfPENSATIdr Lows o, Callforn+a" Colpor-, n h uili o' au <br /> fvo.wa Ich s s pOr e t Is f Ia3 iiia Fc <br /> )1tow,ng 'f CeMf;l tr'I lrr It76 Nerfurmanee of 0--wort.fcr wfrieh In1-perm+t is r5s+led !shah PmpfolAorscns suDJdc"ru <br /> WORKERS c:OMPFNSATION Laws orril,fom+a` <br /> THE A ANT MUST• `ALL 48 WORKING HRS IN ADVANCE FDR ALL REQUIRED INSPECTIONS <br /> �� f/r'/o�ie4. bate 1J L-�o O <br /> /r--� True J /r <br /> 5rgnad Y <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED. <br /> DEPARTMENT USE ONLY Area_�� <br /> � L Jb� Date Issued I <br /> Application Accepted BY O Flnat Inspectlun By Date___ <br /> Grout Irs¢licnan By — <br /> Date <br /> Date <br /> pet.trudjutt inspection By <br /> COMMENTS f CONDITIONS <br /> I <br /> ACCOUNTING ONLY AID0 <br /> PERMIT f SERVICE RCQUhST# INVOtGE <br /> • PECOD1rs FEE INFO AMOUNT RCMITTI D G�IEOK# REc'D F+� r IaTE I <br /> C Ca,rA,{-�.� Tso� <br /> .0-57 LICEN5IM CONTRACTOR MUST' SIc"'Ni , .ICT�,z15L' gcWUILKERS' COMI'Ft'r1�ATION llECLARA <br /> UNIIT IV-6/73199/sign W4pg/MI <br /> 11/02/_000 THT 12 ti [Tl/R3 \11 61781 21002 <br />