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07/12/00 W'ED 10:33 FAX 1 916A& 0430 SECOR-S/:CRAMENTO 2002 <br /> 04!28/2000 e6:23 209468FIFTH FLOOR • FILE COPY Z5 <br /> WELL PERMIT APPLICATION FORM UNIT Iv <br /> ,��(,ot' SAN JOAQU[N COUNTY PUBLIC HEALTH SERVICES <br /> L ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> s� 304 E.Weber, Third Floor, Stockton, CA., 95202 <br /> (209)466.9449 Q 032/ -St <br /> NON-REVUNDABLE PERMIT EXPt s 1 Y O OAYE 133--0 Ilretion Is made in c«npllance with <br /> Application is hereby made to San Joaquin Cou.ry ter a perms w construct andlor install the vrofk described. This app <br /> San Joaquin County DevaiopmerQ Till-,Chaptef&1115.3 and the uhandards of San Joaquin County Public Health SeMIcrS.Envi%SS ePs�r Health'� �D+rO7�^Z3 <br /> WELLL00360 23569 S. San}A Fe R� cross almxt <br /> Cay �;�e;lea k p7IjpQ T.iGw Parceltt <br /> l.,.�:ry r,e SJeV�OAQuJ Address S S"A Fe /1d. JRd Cay ZIP Phonep <br /> PROPERTY Owner gd(-77Z^3570 <br /> C-67 ConVaGef `rfc4t £nv�renatrs'd�deress <br /> ,?T4 SGtirirs n(ar-e- Clp 11 ,p2S252 LIcirLB'865phanetl <br /> (LA.%4' O2. Phoneft 4' B(a1- 0400 <br /> CansultanllSub Cogtrodor -cne (utE'kNAt04+L Address ly ri60'� City rAoa°'^'I LIdP,�._ <br /> s- -k �N� ani p <br /> y Townsnip 3 - --Range. l E/Jr Sedion �y <br /> GIS Cee,d'ulates'X <br /> WORK TO BE PERFORMED <br /> I]DESTRUCTION(Choose type below) <br /> {JEW WELL!BORING(CPT.G(�BE,HT'DROPUNCH,HAND-AND OVER-BORE <br /> GER.OTHER-) <br /> i CIL BORING 0 <br /> Q PRESSURE GROUT <br /> a WELLS <br /> `Other pica re4.t n`J <br /> 40 ,fa.rl�i. rt <br /> COMMENTS 6e p a�2 �0� <br /> ��� off' <br /> TYPE OF WELL iNSTALLATIONTYPE CONSTRUCT NSPEUFICAT10N5 _ <br /> 0 MONITORING U HOLLOW STEM DIA.OF BOREHOLE 3" MULTTI,,PPE OF CASING: BESTEELOIJ PVC WELLCASING <br /> ASI OTHER:- <br /> DEPTH <br /> U Fy,TRpCftON 0 AIR HAMMER/ORNEN CASING F GROUT <br /> "" Y5, TR@MIB.TYPE TO BE USED: XAUGERS eOSE <br /> Q VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL301) <br /> p AIR SPARGE GUSH POINT GROUT SEAL PUMPED:(f Yes p No (NOTE:MAXIMUM FREE-FALL DEPTH IS E <br /> RANO AUGER APPROX.BORING DEPTH 4S" 0 BOLTED TRAFFIC BOX or p STOVE PIPE <br /> 6OHylt R: NG D ° if YES.list speciTrstlons here): <br /> �OTHER: d OTHER CONDUCTOR CASING PROPOSED? � <br /> COMMENTS' ofuNG <br /> 62-1 'w '(l (/C 0. CS 'O�Vv4-t -AS'S' 6c��' A�.E 46 <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I mfy that I nave prepared this application and that the wok will be done in accordance wIN San Joaquin County Ordinances,Stale Laws,and Rules <br /> nereby cooda & <br /> Ig $ � � work <br /> and Regulations of the San Joaquin County. Hermf or Fln hiring Or sub- <br /> Por wfIbis pefmh Is issued,f snarl not empey De toRCOMPENS4TiQN Laws o�lPofa. o f <br /> contracting <br /> synahre eenl0es the following;-I rartJf)r dte!In the performance of the work for which this pennlYs issued.!shall employ persons subject to <br /> wnaecE+zs CCMPSNSA 7101v LaWT Ncelma. gYW'AD. G �flRI; EQnot�ar�N/'' iTIS; <br /> COLI, <br /> - eoR;4�IK?u4[k <br /> Signed x Title/Company AC.OA <br /> pale - it-00 <br /> Plint Name SA�a ` s!^✓r - W` <br /> DEPARTMENT UsE ONLY ) / Q arca <br /> Date lesued- <br /> ADo6eation A=Pted BYDate Final Inspection BY Date <br /> Grout Inapedlon By <br /> Destrudlon Impaction By Date <br /> ACCOUNTING ONLY: AIDN <br /> PECO NTI FEE INFO ADLINT REMITTED CHECK If RECD BY DATE PERMIT!SERVIGS REQUEST R INVOICE <br /> 1/18/2000 <br />