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7/12/00 <br /> a 04/28/2000 WED 10:33 <br /> FAX 2094rEw 0430 SECORF FIFTH FLOOR PACE <br /> ORIGINAL E 3 8' <br /> i WELL PERMIT APPLICATION FORM UNIT IV O <br /> SA JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> NVIRONMENTAL HEALTH DIVISION (PHS-EHD) 111 ll a, <br /> &-- <br /> - 304 E.Weber, Third Floor, Stockton, CA., 95202 <br /> co Rot <br /> (209)4684449 A61st D 0321-51 <br /> µON-REFUNDABLE PERMIT EMIRES <br /> 7 DATE ISSUED <br /> Applkadon Is hereby made to San Joaquin Counb for a permit m construct anGfur install the work deUtbed. Thls application k made b tal He l Health <br /> D with <br /> San Joaquin county Dewalopmen[Tkle,Chepmr S-11 r5.3 and the S4endards of san Joaquin County PubilC Health ServIr EnvimAnnma Neagh Divisipn, <br /> hi Fe Rau-' Crassstreet cty R,,°.b0. k >;p4f r Pace7M 2yg—X70-23 <br /> WELL Location 4359 S. SQn <br /> PROPERTY Owner (AWAY OC rA.)5pARr•t Address 5 �^ Fe (td. JRe4 Ciey Zlp Phona# <br /> C•57Connaanr Aiat &1v"ronwA-1Addrass 3T4 S4✓['t n(Au. _City l�lAll.I, SZip�S252Lldr`$'�BFrSPhone# Zo`f' 7 ?Z-3570 . <br /> RA'"yO 02 Phorleo qlo' B(n1-04p0 <br /> ConsulGntf Sub Controdor -cn2 (utERNAtp.Ni Address !2 ri.�kc R Clty� moanwtLldP,�L_ <br /> GIS Coo nates:% .Y Township 3 �Range EArr section 2•''( <br /> WORK TO BE PERFORMED <br /> y'NEW WELL I BORING(CPT.GHtSD�BE,HYDROPUNCH,HAND-AUGER.OTHER-) p DESTRUCTION(Choose type below) <br /> ,g$OIL BORING C G/?-e p OVERBORE <br /> p WELL# p PRESSURE GRO T <br /> .DSC Gw rdµ <br /> COMMENTS 6e 'irok Rori4• n Cmr r. lt--d 'K^"`' /�"'•t"'Len•�' re..d anl�o-er.•.t �p Sa. r`e Qe,� <br /> TYPEOFWELL I TQI�S ELATION TYPE CONSTRUCT NSPECIFICATIONS <br /> p MONITORING p HOLLOW STEM DIA,CF BOREHOLE 3° MULTIPLE CASINGS7 a YES 9,NC WELL CASING DIA: <br /> p <br /> EXTRACTION p AIR HAMMERrt7R VEN CASING TT1fcKNESS TYPE OF CASING: p STHFL p PVC tl OTHER <br /> p VAPOR 0 MUO ROTARY DEPTH OF GROUT SEAL^ Y5' TREMIE TYPE TO BE USED: r8 AUGERS DOSE <br /> PAIR SPARGE ttU5H POINT GROUT SEAL PUMPED;-Yes 0 No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> -XSOIL BORING p HAND AUGER APPROK BORING DEPTH 4S' p BOLTED TRAFFIC BOX or p STOVE PIPE <br /> p OTHER: tl OTHER CONDUCTOR CASING PROPOSED7P_(If YES,I'Ist specifitmlons Imre): <br /> &14_./ w.11 Gc a 6S Aro4,t �b <br /> COMMENTS: Bon.rrGr <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> neredy aM1ify Nae I nave pmpare IIIb apPlrabon and that the wok wN bs done In acmdance with San Joaquin County Ordtin ngacAft.the per State Laws,and Rules <br /> y,ce of the work <br /> sed Reguledons e1 the San Joaquin Counh• Homeowner or IS Snse �nC 0 s COIf(PENSATMON Laws ofCaadifbmfa."CoM�chr's hldng of sub- <br /> Iarwhich this petm1lr la issued,I soap/IoM emp7py perso+r ulv <br /> puntracdng synalure ceNfles the Ioggwinp:-(csrUfy dtel In the por/ermadCe df fhe vnRr lief which this p2rrhrt:s issued!shall empbY pwspns sdhfect O <br /> WORMCERS'COMAENSATION LawsWCafAwNe.' C:l. EO,F7IRED�r�',d ,TI <br /> Signed x TiUerCompany <br /> I t-00 <br /> PrIM Name SAIF-c c e!^✓! Data <br /> DEPARTMENT DUE ONLY �J /� <br /> Application AccaPled By Date Issued (' V <br /> Grout Inspection By Date Pinal Inspection By <br /> Deswedpn IMPedion By Data <br /> COMMENTS f CONDITIONS: -'r f-60 <br /> ACCOVNTINO DNLY: AID# <br /> PE ccOE3 FEE INFO AMOUNTF111111 TED CHECK■ REC'p BY DATE PrJiNIT ISERVIcfi RCnuESTlM INVOICE <br /> lna/zppo <br />