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.4i Lbi /bud alb:Ys 20946634" FIFTH FLOOR � PAGE 03 <br /> ? ORIGIN <br /> UNIT <br /> WELL PERMIT APPLICATION FORM '-`' " I` - ���1111; ON <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICWJ JL!, I PM 1: 49 <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209)468-3449 <br /> !� NON-REFUNDABLE PERMIT EXPIRES 7 YEAR FROM MATE ISSUED <br /> Application is here made to San Joaquin County for a permit to wnahutt and/or install the work described- This application Is made in cornpllance with <br /> San Joaquin County velopment Title,Chapter 9-1115,3 and the Standards of San Joaquin County Public Health Services.Environmental Health Division. <br /> Assessors <br /> WELL Location 7 156S Saw1a fe iR"A Cross Street City (ZsueY2,40K Lp 7531,7 parcel# 249-070- 011 <br /> PROPERTY Owner bQ-ANN n 11G-JUrayv Address 667 00Farra1 54rre}910 City Fc:su Zip 94109 Phone#y6 I/W-I0-q7 <br /> C•67 ContractorWcs�Nrtw.n� _Jlddress3133?h�cQ X R-k.— CityR-, .Lwd-`Zip95742 Lic#55497l7 Phone#�-63C-7176_ <br /> Consultant l Sub Contractor tiFr --T wAZC 4i,Address l 5°'r r"'kl� Clty2onrJ,>Ic�tlewLldF GI02 Pnone#2r Y6!-OYDO <br /> GIS Coordinates:X .y..Township 3 So-\h Range-9 E(,9 Section Zy <br /> WORK TO BE PERFORMED <br /> ANEW WELL I BORING(CPT,C�EOPROBE,HYDROPUNCH,HAND-AUGER.OTHER•) DESTRUCTION(choose type below) <br /> Q'SOIL BORING# SB-I UOVES BORE <br /> MLL#_ 4114)- _ O PRESSURE GROUT <br /> 'Other._ <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS rl <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLErte_MULTIPLE CASINGS7 0 YES 6C WELL CASING DIA: z <br /> 8 EXTRACTION 0 AIR HAMMERIDRWEN CASING THICKNESS Sclk 40 TYPE OF CASING: a STEEL (j'UVC p OTHER:- <br /> 0 VAPOR p MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: g'AUGERS UHOSE <br /> p AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: p Yes 94a, (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER APPROX.BORING DEPTH 40 0 BOLTED TRAFFIC BOX or []STOVEPIPE <br /> 0 OTHER: 0 OTHER CONDUCTOR CASING PROPOSED? (Il YES,list specifications here): <br /> COMMENTS: 58I W'll 6adr(te }r, 75 C� }Mr6n ew•"'�e �Yrlh-� 5✓R� <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I 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. Homcowrwr or Iloen3ed agent's signature certifies the following:-t eerdry that in the performance of the work <br /> for which this Parrott Is issued,I shell not emplay persons subject la WORKERS'COMPENSA7ION Laws of California." Contractor's hiring or sub- <br /> contracting signature certifies the following:'t certify mal in the porformanea of the work for which this permit is issued.I shall employ persons subject to <br /> WORKERS'COMPENSATION laws of Ca vibmia' <br /> CAL4,'i7(f ) NMT 1 4HSP CIOB 48I1NAR.MkP...... 'ADYAIS(GE1FElR IAC I'gR"EGl;(7IRED'�f i5`PeE_&IC?N5s <br /> Signed x_(Vel( "` //tt Titie1Company SECOR-- Z,,AC,yWA t-�u.nst,1 1 Ike <br /> Print Name -Us 1 Itu(,� t:✓�K1 e- Gwiz- ?r r-C! /0 <djtr- Date 7-10-610 I�qq <br /> Z MI <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Issued 7-13-oO Area <br /> Grout Inspection By Date Final Inspection By <br /> Pit <br /> Destmcdon Inspection By Date D/ <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK B RECD BY MATE PERMIT/SERVICE REQUEST# INVOICE <br /> t �D122� 1-13.00 023 93 <br /> 1/18/2000 <br />