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04/28/2000 08: 23 20946034 FIFTH FLOOR PAGE 03 A y s <br /> ORIGINAL <br /> WELL PERMIT APPLICATION FORM UNIT IV,I ]f, /� <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES-,, 49,'r N <br /> ): -�sV�l <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-END) <br /> 304 E.Weber, Third Floor, Stockton, CA., 95202 <br /> (209) ORIGINAL <br /> 4683449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> AppUcadon is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application k made in compliance with <br /> San Joaquin County Development Title,Chapter 9-1115,3 and the Standards of San Joaquin County Public Health Services.Environmental Health Division. <br /> Assessor's <br /> WELL Location <br /> 135/w S Sola Fo z'-A Cross Street City Rsu e21140,1 7,p 953(57 Parcel# 249-070-1112- <br /> G67 0`1a4 r 154rre}#l0 CityTLF.a..cc,cs Zip 9410 Phone#yh S'yo'1b'j7 <br /> PROPERTY Owner nw�l`+ AG-)U/"`�` Address zoaalz-i5�r' <br /> Ftsd.cMy+o.+r++enlal City 399 Shev.'s PIG/✓� _ U^-11W Spit nSJ 952-$2 683465 - <br /> C•57 Contractor <br /> -- Address _ 'hone#' - <br /> Consultant l Sub Contractor 5E(OR- Address Wil K(5o+`e R.}-S,:k la+ Clty2a+'r-t1O("au.cLlc# G162 Pnone#9 -OyoiJ <br /> Li <br /> GIS Coordinates:X <br /> Y ,Township 3 So✓+h Range I EA s Section Z <br /> WORK TO BE PERFORMED <br /> rNEW WELL/BORING(CPT.GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION(choose type below) <br /> a�SOII BORING - GP- Z G�-3 OOVER-BORE <br /> PRESSURE GROUT <br /> ¢'-YELL# - • <br /> •Other. F' ctv WAk d 'tt &-I (+P'2- -- <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS k( <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS7 O YES H NO WELL CASING DIA:_ <br /> O EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS r._. -TYPE OF CASING: 0 STEEL '. rVG j1 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL + TREMIE TYPE TO BE USED: 81AUGERS OHOSE <br /> O//AIR SPARGE PUSH POINT GROUT SEAL PUMPED: p Yes - (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> 7ySBORING O HAND AUGER APPROX.BORING DEPTH <br /> BOLTED— TED TRAFFIC BOX or 0 S70VE PIPE <br /> 0OIL THERE R OTHER CONDUCTOR CASING PROPOSED? (If YES,list apecifiratlons here): <br /> COMMENTS: — - <br /> (1F-2 GP-3 .• heel.•�c14;,1 {� YS4",� <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby certify that I have prepared this application and that the wak will be done In accordance whit San Joaquin County Ordinances,State Laws,and Rules <br /> and Regulations mrIans of the San Joaquin County. Hameo'wrxr or Licensed agent's signature Certifies the follovnng:-1 Certify drat,n the perforrrrance of the work <br /> lar which this permit Is issued,I shell not employ persons subject to WORKERS'COMPENSATION Laws of Cal7/omfa." Contractor's hiring or sub- <br /> contracting signature certifies the following:-I ceNTy thal In the performance of the work for which this Penni[lo issued.I shall employ persons subject to <br /> MPXERS•COMPENSATION Laws of Cahfomla." <br /> kLLrkSP CTOR 4811d►(A l�[N6F3RS IN ADV .IC _.FOCtA4,IR ,l7IRED IPi�`PL? i IOR(5; <br /> Signed% �'� Ql- Title/Company SeCOIL -Sv�A,-,Yw4c,41 1 Ike- <br /> Print Name a <br /> Tt1 Acv l v G 6[oZ Pr�EcI AIw oer Date 7-1D-bb <br /> uc. <br /> DEPARTMENT USE ONLY ( 1 —Oy Area <br /> Apolwation Accepted By <br /> Date Issued i <br /> Grout Inspection By <br /> Dale Final Inspection By <br /> Destrucdon Inspection By Date <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK B RECD BY DATE PERMIT(SERVICE REQUEST# INVOICE <br /> 101 ay8 CIS -7-13 SR# DV2 3 <br /> t/fa/zaoo <br />