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AUG 05 '99 16:54 FR LFR LEVINE FPICk,E 510 652 4906 TO 12094583433 P.02i05 <br /> *ILE s8-sic " <br /> WELL PERMIT APPLICATION FORM UN ' _ A L <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES Q <br /> ENVIRONMENTAL HEALTH DIVISION ("PHS-EHD") <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 - Z�� L✓ <br /> (209) 468-3450 -/CCO /� � <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ) � <br /> 4ppficalion is hereby made to San Joaquin County for a permit to construct and/or instaN the work described. This application is made In compliance with <br /> San Joaquin County Development Title,Chapter 31115.3 and the Slandanfs of San Joaquin County PUDNc Health Servi®s.Environmental Health Division. <br /> a ��,,EE�.vrr..a �� RcrvJwn�p N�•r Lia 9a-he, rwn •/ 6Rrryr0ra6 A. ,C: Assessor's <br /> WELL Location Bt1 � Cross Street Cx>nr�.«r A. City rfzkr _- Zq Parcew <br /> r <br /> PROPERTY Owner�i.r_rwev.�i l'ev,�ri Address City Z1p PheneN <br /> r <br /> 7-5T Conbaaor r4Vr+4e.. Address ZSz.r bJ,6 1- 47R. Cay rar ZIP Srzor-Licx uz-j& Phone#_L o9F2jrLr L <br /> -67/ <br /> :;Wsuluntl Sub ControctorlFR Cf,•,C /YGAdrKLG Address IfeD 42vR� f,-, /Let City-F R}_N idl ➢hone#V.ro�59f-76aY <br /> :;IS Coordinates:X Y.,Township Range Section <br /> NORK TO Be PERFORMED <br /> JOIEW WELL I BORING(CPT.GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> -0-fiOIL BORING a a , / 1 0 OVER-BORE <br /> u WELLd �rj�} y j 0 PRESSURE GROUT <br /> 'Other. <br /> COMMENTS. <br /> rYPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br /> D MONITORING HOLLOW STEM DIA OF BOREHOLE 6-n ty MULTIPLE CASINGS?0 YES 0 NO WELL CASING DIA:! <br /> 3 DC MCTION 0 AIR HAMMERIURWEN CASING THICKNESS n/ r` TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> C VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL O-po',9cs TREMIE TYPE TO BE USED. ArAUGERS DHOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: VYes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> IrSOIL BORING 0 HAND AUGER APPROX.BORING DEPTH ,3d-kfr 91.L—0 BOLTED TRAFFIC BOX or D STOVE PIPE <br /> j OTHEp_ CONDUCTOR CASING PROPOSED? .11/, (if YES,list specification hen:): <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS! <br /> hereby Certify that I have prepared the appirotion and that the work will be done In accordance with San Joaquin County Ordinances,State laws.and Rules <br /> and Regulations of the San Joaouin County. Homeowner or licensed agent's signature certifies the following:"I carl/fy Nat in the perfbrtnance Of the work <br /> Lor Which MIs permit Is Issued,I shall not employ persons subject to WORKMAN'S COMPENSAT70N Laws of Callfornia." Controoldes hiring or sub- <br /> writraq#hg signature certifies Me following:61 corlify that in pre performarrce of the rrdrk for welch this permit Is issued,I shall employ persons subject to <br /> VWRKMAN'S COMPENSATION Lews o/California.' <br /> / THE APPLICANTT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed x �Avf '� TNe /�.awEr7 eSFavecar Gate 077899 <br /> SEE SITE MAP I UNIT IV WOR=K DATED <br /> DEPARTMENT USE ONLYOa <br /> gpplimtion A¢epled By Date Issued [C / <br /> Grout Inspection 8, Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS' Q <br /> ACCOUNTING ONLY: AID# "FA010PE CODESFEE INFO AMOUNT REMITTED CHECKXICASH RECEIVED BYMITISER''VICCnE REQUEST NUMBER INVOICE <br /> Q W <br /> J0,117T tV-5/99/MT <br />