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04/12/01 THU, 15:47 FAX 510 6F `141 GEOMATRIX OAKLAND 1_, • 002 <br /> JAL? <br /> WELL PERMIT APPLICATION FORM vv UNIT IV <br /> SAN JOAQUIN,COUNTY PUBLIC HEALTH SERVICES <br /> ✓C.� � ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) $uR� <br /> �wp ,(l•+,C. 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209x 468-3449 ! _ CVRtd ui <br /> �T �v <br /> NON REFUNOABLE P„F,RM1T EXPIl5E5 1 CSAR FROM DATE ISSUI50 <br /> Application is heraby made to San Jeariuin County for a penTdt to construct and/or install tho work described. This application is made in complimce with <br /> San Joaquin County Development Tltie,Chapter 4-1115.3 and the Standards or San Joaquin County Public Health Services,Environmental Health Division. <br /> Assessor's <br /> WELL Location IS3Or k ZIKV E. ole Carrel h1,JW Fd Cross Street 1A1 koliou City Ira&,., Zip Parcato <br /> °/V:5"F,oF A1dM Fbikdr•. IJes+ ttri Yinr..3 aS>L Si.t� Srr0 [D <br /> PROPERTY Owner W �?a0 <br /> +tge A44 Address City _ Zip Phdne <br /> Ztty of yYn4� Z"37-9$-15' <br /> C-57 Contractor5—Mpi1 Tn�.Addresa rye S, V61% 5rI- City ��4hmorl� 2ipyIVYb,Liclk 1`3636? Phonetlrklo]66R 4 <br /> ConsultantlSub ContraCtarC«nsvN Ak Aold ress'&101tJt.bSkA- 54- city`Q%KIw-e) Licit Phonats�c�(,1�3�Zce <br /> IY^J live <br /> GIS Coordinatas;X ,Y Township Range SeGdan <br /> WORK TO 9E PERFORMED <br /> NEW WE"490RI NG GPT,GEOPROBE.HYD ROPUNCH.HAND-AUGER.OTHER*) Q DESTRUCTION(ctroase type below) <br /> SOILBORINGIK GIWX-3 GMS-41 GMY, wdmt9srir-n�bm b..atep:rl*rl OVER-8t1RE <br /> WELL 4 wI came r.ge614-4r b.ivbm 4v►vp 0 PRESSURE GROUT <br /> 'Other wl trarwrti:e P:oe �tkrJ:a3 52���0. <br /> COMMENTS, <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Q MONITORING Q HOLLOW ST>rM OIA,OF 60REHOLE jr MULTIPLE CASINGS?0 YES P NO WELL CASING DIA: <br /> 0 EXTRACTION Q AIR HAMMERIORIVEN CASING THICKNE35 Alh4 TYPE OF GASSING: p STEEL Q PVC Q OTHER: <br /> p VAPOR Q MUO ROTARY DEPTH OF GROUT SEAL Alhd - TREMIE TYPE TO BE USED: Q AUGERS 13HOSE <br /> 0 AIR SPARGE PUSH POINT GROUT SEAL PUMPED: 0 Yes 11 No (NOTE: MAXIMUM FREE-FALL DEPTH IS,30') <br /> SOIL BORING Q HAND AUGER APPROX,BORING DEPTH 2!r' rvl&A. 0 BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> 0 OTHER' 0 OTHER CONDUCTOR CASING PROPOSED? (U YES,list specifications here): <br /> COMMENTS: D teed atti r' 11 fi� �iil dritlfsnnwR({ a mw dfpltti a� �5' InS}dLlMa 1'' et:a- PVG Gas:nt <br /> !4 <br /> C1 *-I sew 4v s-^-p qra yflal�.dka. All b}Rf', o 11;Ik-VG sGIG(�a�ttr� w� �P /L+ �ra v�- lJr'a �t.►lAt r.G Q: 4 I :,vc Sw«'I'e <br /> ..�L cleNOTE. OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMEAI-i' PERMITS <br /> I hereby Cof*that I have pmparrd this application■nd th■t the work wilt be done in accordance with San Joaquln County Ordinannies,State Laws,and Rules <br /> and Regulstiorm of the San Joaquin County. Homeowner or Ikensed agenrs signature cArtifies the following:"1 cvrtrfy that In tho parfornranca of fho work <br /> far which this permit is Issued,1 shall rrdt employ Persons sabjdef in W0RXERS'COMPENSATION haws of Californ4." Cantrzc=es hiring or sub- <br /> contracting signatu rn certifies the following: 7 cardly U►of n the Qerlbrplanee 001,10 work lbrwhich this permit is Itat od, I X11 employ ponos suble&In <br /> WORKI=AS'C10MPFNSA770N Laws of Calffarnia,- <br /> T E PLICANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> r <br /> Signed x 7 IIIc A�to _r Data <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Issued <br /> Grout inspection By Date Finn{Inspection By <br /> Destruction Insgectlon By Date ' <br /> COMMENTS I CONOITIONS: 2- G <br /> /�_ �✓ l d <br /> FAC* ld <br /> ACCOUNTING ONLY. A109 OD 2a <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK10CASH RECEIVED BY OATS PERMITISERVIGE REQUEST NUMBER INVOICE <br /> Z9-D) b S1•'� $`�3 <br /> ww <br /> UNIT ICV-8/23199/sign bkpg/MI <br /> z0 3�tld 23Q0�� HJ.�I� E£b£89b60Z 00�pti 0@0Z/Zi/h0 <br />