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08/24/2001 09 36 2094683433 FIFTH FLOOR PAGE 01 <br /> w <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> • SAN JOAQUIN COUNTY PUBLIC HEALTH SRVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PH -EHD) <br /> Th,304 E weber, ird Floor, Stockton, CA., 5202 <br /> (209) 468-3449 <br /> NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin CounV for a permit to construct andfor Instep the work de3c0ed This application is made in compliance with <br /> San Joaquin County Davelopment Tltla,Chap t 9-111 3 and the Standards of San Joaquin County Pubfie ealth Services,Envwonmental 111eE31th Division <br /> ` Assessors <br /> WELL Locatlon �`�` I- m 4 Cross Street.1' S6 City TrU rip Parcel <br /> PRCIPERTY Owner 1� i 'JA� Address p1 lr��ui r'Ja" r, City 4 ip T a Phone# _ <br /> C-67 Contra=6&A Ir; �,. w! Add s it:G� pew", �� C Ltoo5261 Phone*'�J�— t 3 <br /> CorssultantISubContractor A. 111Y Addreis3� i< -,-Yf1City ^ C L+c# Phanei1 p-6f ` <br /> GIS Coordinates X Y_ township Range Section <br /> WORK TO BE PERFORMED <br /> XNEW WELL I BOEING(CPT,GEOPROBE,HYDR P H,H D ER,OTHERI p DESTRUCTION(choose type below) <br /> U SOIL 130RIN� - a OVER-BORE <br /> 01NELL# — p PRESSURE GROUT <br /> •Other" <br /> COMMENTS <br /> TYPE of WELL INSTALLATION TYPF= CONSTRUCTION SPECIFICATIONS <br /> '00N1TORING fl HOLLOW STEM DIA OF BOREHOLE —10 MULTIPLE CASINGS-1 D YES klilO WELL CASING DLA <br /> a EXrRACTION `D&R HAMMEPJDR1VEIJ CASINGTHICKNESS TYPE OF CAST G B STEEL Q PVC a OTHER` <br /> G VAPOR )MUD ROTARY DEPTH OF GROUT SFAL�'+r4�rs�TREMIE TYPE TO HE USED <br /> B AUGERS OHOSE; <br /> 100 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED `)tYes a No (NOTE-- 111AXIMUM FREE-FALL DEPTH IS 30') <br /> OIL BORING Q NAND AUGER APF�R4X $DRING DEPTH >�t10' _ _ '0$ LTED TRAFFIC BOX or D STOVE PIPE <br /> 0 OTHER a OTHIaR CONDUCTOR CASING PROPOSED) <br /> (if Y S Fist specrfrcations hers} <br /> C M MENTSU r, rt r c. Cu ,► r,, r f I C� <br /> 16t r4 <br /> NOTE; OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Jo quin County Ordinances,Stara taxis, and RuIe5 <br /> and Regulations of the San Joaquin County Homeownar nr licensed agents signature certifies the follovring 17 cetVfy that in the performance of the work <br /> for which this Perinif is issued,i shall not employ persons subject to WORKERs'COMPENSATION La s ofWMarnla" Contractor's hiring yr sub- <br /> contracting signature certifies the followrng I cert+fy that in the perforgpance of the 4,oitk forwhrch this Pemtit r issued, I shall employ persons subject to <br /> Wt7RKERS'COMPENSr4T10N Laws of CaGfoMId <br /> X-R!MI . <br /> MIA <br /> Signed r TtUe l tic 'r1 U <br /> Date <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED 5 0 � <br /> DEPARTMENT USE ONLY <br /> Applltation Accepted By Date Issued <br /> Grout Inspection By D _ Fina[Inspection By pate <br /> Destruction Inspochon By Data <br /> COMmENTSI CONDITIONS <br /> ACCOUNTING ONLY AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK$ RECD By DATE PER IT/SERVICE REQUEST V INVOICE <br /> "$ a-7 a-3 t,� f I;)— <br /> vNTT LV-4/29/99/sign bkpg/Mr <br /> i' d Mi Nvvs i t CE�6 L—60—Z L <br />