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{ 1-28-2000 2:41 PM FROM <br /> : '. <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH-DIVISION (PHS-EHO) � C <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 Y <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> pplication 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 <br /> >an Joaquin.County DelOpennt Ti!1e`, �a ter 5.3 and the Standards of.San Joaquin County Public Health Services, Environmental Health Division. <br /> G�Ofb 'fj{, r Assessor' <br /> VELLLocation YC.�D Ns as Cross Street Gra.�1!'.5F, City 1 �1e:� Zip 9S6'8d Parcel# bol^230-2:> <br /> 'ROPERTYOwner TA, I��II•ty Cfoc4�fAddress da0 Qra City lLio��sv. ZipPhone# � 5 � l <br /> -57 Contractor Woa�wr.E 6A:.&I .,. Address ?ode � - Citfy� Vhs ZiplytLt Lic# 7fe 01 Phone#78 7 37y rV3e0 <br /> :onsultant 1 Sub Contractor_ EYa!�d ,.ate �.S£ Address10.26Lsev..���tity re-, Lie# Phone# 3 <br /> 3IS Coordinates:X Y Township Range Section <br /> NORK TO BE PERFORMED <br /> 3 NEW WELL 1 BORING(CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER,OTHER*) , DESTRUCTION(choose type below) . <br /> O SOIL BORING# 3 O OVER-BORE <br /> 1 O WELL# O PRESSURE GROUT <br /> Other: - 4,Xar «SSO-e 4rllly .±t_ arw, o^Le �.•�[ �•5• wt�fS �,..I,-S{c�- 13 /7 _-- <br /> pate welt +o a .,.s �.l a t,e -fof Jeplh, ;. <br /> COMMENTS: <br /> i <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ,f-MONITORING (]HOLLOW STEM DIA. OF SOREHOLE 4C" MULTIPLE CASINGS?Il YES )•NO WELL CASING DIA:;^ <br /> O EXTRACTION O AIR HAMMERIDRIVEN CASING THICKNESS Q.L" TYPE OF CASING: O STEEL ArPVC O OTHER: } <br /> O VAPOR O MUD ROTARY w DEPTH OF GROUT SEAL i< TREMIE TYPE TO BE USED: O AUGERS OHOSE 1 <br /> O AIR SPARGE ©PUSH POINT" GROUT SEAL PUMPED: 1]Yes t3 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') } <br /> O SOIL BORING p HAND AUGER APPROX.BORING DEPTH O BOLTED TRAFFIC BOX or O STOVEPIPE <br /> O OTHER:_G OTHER CONDUCTOR CASING PROPOSED? (if YES, list specificaticns hese): <br /> COMMENTS: Weds T "' as 41M"1` •Fe 6e .eS:.r— r*d <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> f hereby certify that 1 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 certify that in the performance of the work <br /> for which this permit is issued,t shall not employ personssubject to WORKERS'COMPENSATION Laws of California." Contractor's hiring or sub- <br /> contracting signature certifies the following: "1 certify that in the performance of the work-for which this permit is issued, i shall employ persons subject to <br /> WORKERS'COMPENSATION Laws of California." . <br /> CACI NlT.4 .' SPECT OR 48 WORKING HRS�1N APVANCt , R AIL REQUIRED INSPECTIONS. <br /> Signed x TittelCompany 'oGla T C G'eole <br /> Z 7_4 <br /> Print Name _.,,, O _ _ _ <br /> ate <br /> a ��h Y I F <br /> V ..�./ J.AtIJ'I�Y 1 �( <br /> i-._' � '� .....i_kL._.G=awl{{n�.,Hm,...Lw........::�'i•�- .� r�L....-3.-�.7av'1M1. ..y..... .� . <br /> DEPARTMENT USE ONLY J /}� <br /> Application Accepted By Date Issued 3 f-7 —O{ Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> FACCOUNTING ONLY: AID* <br /> ti <br /> E CODES FEE INFO AMOUNT REMITTED .1 CHECK# REG'D BY}.. DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> 3so2 Usk faD.� act �/ " z 7 002-5411 <br />