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06/20/2000 09:52 2094683433 FIFTH FLOOR PAGE 02 <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTYPUBLIC HEALTH SERVICIME'EV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 JUN 2 8 2000 <br /> (209) 468-3449 ENVIRONMENT HEALTH <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT/SERVICES <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance 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 /> n �n Assessor's <br /> WELL Location 10 t)i �� �`l kC Gi At)PVC111 street City -G+CC��K)Zip 5vu�o�Parcell! 1/t�- i`I(��O� <br /> PROPERTY Owner \1\VQ( �A Cr���rQ Address J�'U &c� ,i tzAVe. _city SmcL-�4ayA - rp��o �fiane# \���9'4C--1 <br /> C-57 Contractor t ( � Address a city LFu�ZIp�J 457/1icu�CS`1d�t,one# 1 (n 7(n7� <br /> ��u: L "1O011r�\�te�� ev��z CC �_( c�-LI.SOO <br /> Consuttant/Sub Contractor Y6f',me vi i Address G ty cru„nP,ALic, Phone# ftb S T <br /> �cAE,1c� ASSC2kZ '� 5w 1. O <br /> GIS Coordinates:X —.Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> Q/NEW WELL/BORING(CPTPROBE, YDROPUNC HAND-AUGER,OTHER') 1]DESTRUCTION(choose type below) <br /> OIL BORING# f: ()OVER-BORE <br /> WELL# <br /> 13 PRESSURE GROUT <br /> *Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ()MONITORING 0 HOLLOW STEM DIA.OF 13OREHOLEA"MULTIPLE CASINGS7 0 YES `�I NO WELL CASING DIA N� <br /> 0 EXTRACTION p AIR HAMMERIDRIVEN CASING THICKNESS fo 4 TYPE OF CASING: WSTEEL 13PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL N 4 TREMIE TYPE TO BE USED: 0 AUGERS CHOSE <br /> 0 AIR SPARGE GUSH POINT GROUT SEAL PUMPED: p Yes R'No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> [-SOIL BORING II HAND AUGER APPROX.BORING DEPTH c � s 0 BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> IJ OTHER:_0 OTHER CONDUCTOR CASING PROPOSED? fUR (if YES,list speafcations 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:"I eerdfy that in the performance of the work <br /> for which this permit is issued,I shall not employ persons subject to WORKERS'COMPENSA TION Laws of California." Contractor's hiring or sub- <br /> contracting signature certtfles the following:'I cerlify that In ft performance of the work far which this permit is issued,I shall employ persons subject to <br /> WORKERS'COMPENSATION Laws of Cabyomla.' <br /> CALL THE <br /> �UNIT <br /> j IV INSPECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS <br /> Signed x- krr�c\, cc�� ' \� Tltie/Company <br /> Print Name , ( L� '_TA7 1 Date LO/r 10 0 <br /> LA`c\\�4 J C,�- -��`�OLG��tZ l Lug( W <br /> SITE FILE ADDRESSlWORK PLAN DATE: `���e ��L o�h�r,� •?w� l>�',�LDI�r`,F.���v�e 4�;c�,(,a <br /> DEPARTMENT USE ONLY <br /> Application Accepted 8y Date Issued a-- cj6 Area v s� <br /> Grout Inspection By. Date Final Inspection By Oate <br /> Destruction Inspection 8y G G� z_E"G Date -7- ( , C )„�-- <— ,) e <br /> COMMENTS/CONDITIONS: `-t <br /> ACCOUNTING ONLY: AIO# FArA <br /> PE CODES FEE INFO AMOUNT REMITTED I CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST 0 INVOICE <br /> 3svt �� C) <br /> C-57 exp,!WC/waiver_ C-57 Letter of Authorization to sign permit Encroachment doc(s). 5/17/00 <br />