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64/26/2000 08:23 2094683a=�^ FIFTH FLOOR PAGE 03 <br /> - 01 , ORIGINAL%5 <br /> /- WELL PERMIT APPLICATION FORM <br /> UNIT IV <br /> C2�G� 0- � . <br /> (6, SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION A., 95202 <br /> 304 E.Weber, Third Floor, Stockton, CA., 95202 <br /> (209)4683449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM HATE ISSUED <br /> Application is hereby made to San JNq Chapter 9-11rt 5,3ermit to construct and/or install and the Stands ds of San Joaquin County public Health Services.Environmental ntaade in all HHelalth Division. <br /> San Joaquin County Development TRie, 1 p Assessor'�_O..r�_^" <br /> WELL Location r <br /> 2.35(95 S 74A� Fe l A-Cross Street City Z (t.A Zip�347 Pa;cefN -0 <br /> '3 SbS $. AA y'`34T Phone#C7L5) 836- 7543 <br /> PROPERTY Owner Si.KLr\ Pn,/��'010. Address .fes Fe Q�+ City R+Ut>bGnk Zip <br /> C•67 Contrac[orl z 4l� M1'uk Adtl2ss 3233�'i-zn _� n'L3 City ��`�"+ Zip fS74L Lic#5sHG7f7 Phone#111C. 33e-7L7Z <br /> i p,.(. ,'k l� CIt I'Kt &,kA LIdF4tbZ Pnone#9/� Ski-bYoy <br /> Consultant f Sub Contractor s eCOZ �'�•�'�"-b"k( Address 3D 7 K /e°• y <br /> GIS Coordinates:%�Y <br /> Township 3 Sc.yh Range Q Ea'} Section ZLi <br /> WORK TO BE PERFORMED <br /> ()DESTRUCTION(choose type below) <br /> JEW WELL/BORING(CPT. EOPROSE,HYDROPUNCH,HAND-AUGER, '1RR') 0 OVERBORE <br /> yi OIL BORING S 'Z OPRESSURE GROUT <br /> 'Other: <br /> &r; is /vw z <br /> I to rxr� L�'7 2 wGllt 4�r.t l-ES f}. <br /> COMMENTS / fleep bnr >--a, �g <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS rn <br /> )(MONITORING ) OLLOW'=RIVEN <br /> D[A.OF BOREHOLE 8„ MULTIPLE CASINGS?0 YES }JO WELL]OTH5 DW <br /> -2L <br /> EXTRACTION 0 AIR HAM'=RIVEN CASING THICKNESS ! d- L/D TYPE OF CASING: 0 STEEL ' PVC 0 OTHER: <br /> O VAPOR *dUD ROTARY DEPTH OF GROUT SEAL b�—TREMIE TYPE TO BE USED: AUGERS $HOSE <br /> 0 AIR SPARGE0 PUSH POINT GROUT SEAL PUMPED:)K Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> g'SOIL BORING U HAND AUGER APPROX.BORING DEPTH 440' oz gBOLTED TRAFFIC BOX or p STOVE PIPE <br /> 0 OTHER' fl OTHER <br /> CONDUCTOR CASING PROPOSED?— (if YES, list spec ticatlons here): <br /> COMMENTS: -S-c( = eTo �� I �:J <br /> n {cf OI SPM W <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHM NT PERMITS <br /> I hereby certify That I have pttpared this application and that the work will be done In accordance with San Joaquin County Ordinanms,State Laws,and Rules <br /> and Regulations of the San Joaqutn County- Hamcwrner or Licensed agent's signature certifies the following: "1 cerdty drat;n/he performance of work <br /> for which this permit la issued,I shell not employ persons subject to WORKERS'COMPENSATION Laws of Cafifomia." Contractor's ohnng or <br /> s subject to sub- <br /> for <br /> signature cenifles the following 1 Get*that in the performance ofthe work lorwhich this permits issued.!shell employ Pe la <br /> WORKERS'COMPENSATION Laws of California.' <br /> cAu ,3Tr i)t�I a spJEeTOR 4VWPR-K(R s IH ADYtNKIEEIFOR, LLIf2 G1l7IRED�Ksr app s; <br /> Title/Company StCDZ Zn�crna� ��al �-HG <br /> Signetlx� C�1[� nn / <br /> Print Nerne I-tvLltft�-�Urtl� Date 7-1b-00 I�pp <br /> NI <br /> DEPARTMENT USE ONLY () O(.nK <br /> Date Issued Area N" <br /> Application Accepted By Final Inspection By Date <br /> Grout Inspection By Date �1 <br /> Destructor,Inspection By Date <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK a RECD BY DATE. PERMIT I S RVICE REQUEST# INVOICE <br /> tAw IDI 2z 39 1/18/2000 <br /> a � e7Lt; ✓o/c. <br /> GCI) �=� sic <br />