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11/28/2000 16 29 2094683433 FIFTH FLOOR PAGE 01 <br /> WELL-PERMIT APPLICATION rdRM UNIT IV <br /> SAN JOAQUIN COUNTY Post-it"Fax Note 7671 Date fl ats od page-► I <br /> ENVIRONMENTAL HES To X70, � From or- bv-,Ica� <br /> 304 E. Weber, Third FI ColDept Cn s,7-C, <br /> (209) Phone iF Phone it zo9 i+b 19D!3 3 <br /> NON-REFUNDABLE PERMIT EFax p 1 Ij 7j S r�$ Fax# <br /> 4pplic2tion is hereby made to Son Joaquin County for a permit to construct anofar Install the work described This application is made in compliance with <br /> an Jcaqurrl County Devetopment Title Chapter 9-1 v$3 and the Standards of San Joaquin CDunty Public Health Services Environmental Hpalth Division <br /> ' <br /> ELL LocationrossStreet5HERMAVA_391 MOfFAI 8LVp, CR11 iIy MA1�TisCa Zip Assessors <br /> 5336 Parcel# s -C3-� <br /> SAN V3AQVIN COUNTY <br /> ROPERTYOrrner ULU,ITES Mkl'IT DEP-1 I171V 5GCTT5 AVE CitySTOGKTVN zip9_5101 Phone#-2C9-qGZ-335 <br /> 57 ContractorV4WPAILLINGIINC_Address U.ac 416City 15LLTONzip956LFcu9� Phoneug«- �} 4100 <br /> ConsultantISub Contractor_ RAMAG-F_ E�(1). Address P•0 8k 69 CilyMur�I TA Lttf1 gjtS_ Phonett9lb-'3,54 --SO <br /> FISCoordinates X —,y Township Range Section <br /> WORK TO BE PERFORMED <br /> NEW WELL/BORJNG(CPT GF-OPROBE,HYDROPUNCH,HANQ AUGER OTHER) Q DESTRUCTION(choose type below) <br /> p SOIL BORING* 0 OVER-SORE <br /> 'Other I'rl l <br /> WELL F—MN` E1 JwI -3,_ 0 PRESSURE GROUT <br /> OMMENTS <br /> PE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIE{CATIONS <br /> I MONITORING III HOLLOW STEM DIA OF BOREHOLE S-IN MULTIPLE CASINGS?D YES !NO WELL CASING DIA Z'IN <br /> CTION Q AIR HAMMER/DRIVEN CASING THICKNESS SEH 40 TYPE OF CASING 0 STEEL `PVC BOTHER <br /> OR a MUD ROTARY DEPTH OF GROUT SEAL I3"F T TREMIE TYPE TO BE USED J AUGERS BHOSE <br /> U AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED a Yes I No (DOTE' MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER APPROX BORING DEPTH_ 0" T BOLTED TRAFFIC SOX or p STOVE PIPE <br /> OTHER CONDUCTOR CASING PROPOSED-2 NO (if YES,list specifications here) <br /> �OMAAENfiS <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS} <br /> 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 /> nd Regulations of the San Joaquin County Homeowner or licensed agent's signature certifies the following "f certify thst in the performance of the work <br /> f which this permit is issued, f shall not Employ persons subject to WORKMAN'S COMPFNSATtON Laws of California" Contractors hiring or sub- <br /> contracting signature certifies the follovnng 'I certify that in the performance of the work for wh,ch this permit is issued l shall employ persons subject to <br /> ORKMAN'S COMPENSATION Law of Cafrfornia , <br /> THEPLl NT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSP CTI NS <br /> Signed4�4* ff - Till Date <br /> 13EE SITE MAP IN UNIT IV WORK PLAN RATED IQ Ial 99 MAP ATIA 6" <br /> DEPARTMENT USE ONLY <br /> pplication Accepted By Date Issued <br /> rout inspection 8y Date Final Inspei:1 o By Dale <br /> Destruction Inspecton By Date <br /> IIJOMMENTS l CONDITIONS <br /> FACtt <br /> UNTING ONLY AIDII <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKO/CASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBED INVOICE <br /> 3sol se9 1 63 ,I oozy b <br /> 'NIT IV-6/1/99/sign bkpg/MI <br />