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02/26/2002 08.22 2694683433 <br /> FIFTH FLOOR PAGE 132 <br /> ` WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-END) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NO"EFU DAIS E PERMIT EXPIRES 1 YEAR FROM DATE tSSLJED <br /> Application is hereby made to San Joaquin County for a permit to construct andlor Install the work described, This appimsdan is made in compliance with <br /> San Joaquin county Deveioprnent Twe,Chapter 9-11 is 3 and the Standards of San Joaquin County Public Health Services, Environmental Health D)vlspon <br /> Assessors <br /> WELL Location 1805 1641 c %mA Cross Street 4,�e%IORJS; Csty in Zip �+`7. _!. Qssm <br /> PROPERTY Owner fe �et.� dress„''1?5 W. FI 2ena4o S}_ C1 ISJM IES+ Zip 52n Friona#�04�482-834 <br /> C-57 Contrer:tofWw4 wo til�r��:ww Address�C tInSR 33dCItyg..V t& Zip 9!fS7_ Llcik'I-�aoT4-Phone# <br /> •deittCf--ti.Nk"&' . , • � r <br /> Consultant/Sub Contractor Oaw%4 W. oa. Address i+'lo 6.fadh D!:4 17e Cu�..�G49LAc# ;t Phone# <br /> CIS Coordinates'X -1y Townshlp Range Section <br /> WORK TO BEP RF ME r: r <br /> KNEW WELL 1 BORING(CPT,GEOPRODE,HYDROPUNCH,HAND-AUGER,OTHER•) a DESTRUCT10N(choose type below) <br /> B SOIL BORING# 11 OVER-BORE <br /> WELL# -It. k,•' Ia PRESSURE GROUT <br /> 'Other: <br /> COMMENT'S <br /> D INSTALLATION TYPE CONSTRUCTION SPECIFICA IONS <br /> ITORING 0HOLLOWSTEM DO,OF BOREHOLJ: 8 f` MULTIPLE CASINGS?0 YES x'+10 WELL CASING DIA. _ <br /> 0 EXTRACTION D AIR HAMMERIDRIVEN CASING Th1ICKNESS,'S� TYPE OF CASING, D STEI`L IMpvc. I>OTHER <br /> D VAPOR D MUD ROTARY DIEM OF GROUT SER 46"t `7 S'TREMIE TYPE TO BE USED, [I AUGERS DOSE <br /> D AIR SPARGE []PUSH POINT L3ROUT 5FA1 PUMP>'D Was p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> 0 SOIL BORING a HAND AUGER APPROX BORING DEPTH 66'� 9D' *tOLTEG TRAFFIC BOX or I?STOVE PIPE <br /> 13 OTHER;_Q OTHER CONDUCTOR CASING PROPOSED') NO (if YES,Inst specillcminns here) <br /> COMMENTS <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby certify that I have prepared this application and that file work will be dons in accordance with San Jcactuin u►sty Ordinancea,State Laws,an Rules <br /> and Regulations of the San Joaquin County Homeowner or rcensed agent's signature certifies the following. N cerllfy that in theperlormance of the work <br /> !or which this penali Is Issued,l shall not erpmpbypersons subject jo tNORkI=RS'CIaMPENSJ4770N[ ws of C$(}fpMTaa” Contradots hirlrrg or Sub- <br /> contracting signature certifts the foliowurg 1 ceAVy that In the penbrmnnoe of the work Thr wi%m Mis permit is issued, t sbalf ieinploy pemws subfad to <br /> IMCRKERS'CQMP9tJ3ATON_/.sets of c4iorww <br /> _ <br /> ; PM LI NT,U PALL~+FS OR ANG yRS`,a�l�l ADVAN9 19TO <br /> Signedvo <br /> SEE SITE MAP IN UNIT Ill WORK PLAN DATED: _VIc.snobgc it Zook <br /> DEPARTMENT USE ONLY <br /> Application Accepted 6y + 13ae Issued- <br /> Grout <br /> ssuedGrout Inspection By hate ` 'Ftr►at Inspec dor+Sy •� , ' �� _ ''tate <br /> Destruction lnspecttan By pate <br /> MMENTS I CONDMONS• 140CA <br /> A"tCOUNTING ONLY' AID# <br /> PE CODES Fr%E INFt) AMOUNT REMITTED CHECK* RECID BY BATE PERWT I SERVICE REGUM# INVOICE <br />