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04/28/2000 06:23 2094883d''' FIFTH FLOOR PAGE 03 <br /> ORIGINAL <br /> � <br /> WELL PERMIT APPLICATION FORM UNIT Iv <br /> b� <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES � <br /> y� p ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E.Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 4683449 <br /> NON-REFUNDABLE PERMIT EXPIRE-1 YEAR FROM DATE ISSUED I,c=tbn Is made in compliance with <br /> Applkadon is hereby made to San Joaquin County fora permit to construct andior install the work described. Thls app <br /> San Joaquin County Development Title,Chapmr S-1115,3 and the Standards of San Joaquin County Public Health Services.Environmental Health Division. <br /> WELL Location <br /> 23laSQ S1. Sa^S � "CrossStreet City t" •:nk Zip�34o-7 Parcel#.?Y!-070—/0 <br /> an 19534") Phone#Z'N 5169"Zf3 <br /> PROPERTY Own Fers�l 332ggdr Stie� k-,F: S. fun E'C lley soy+sl Y�zS� �1t384S ZAP 77z-3flrz. <br /> ddres:-. CdY.____ _ ._ip. _`Lic#_ . . Phone# _- <br /> C•67 Contractor �` <br /> Consultant f Sub Contractor SLCOz 1�+1e�c.u- •na� Address3a0k;l,ar1'-� '�114140 City---d'° 10L Phone#4! $GI-04a� <br /> GIS Coordinates:X .Y ,Township 3 Range q &± Section Z r{ <br /> WORK TO BE PERFORMED <br /> JEW WELL!BORING(CPT,Gl�BE,HYDROPUNCH HAND-AUGER,OTHER') a DESTRUCTION(choose type below) <br /> *`SOIL BORING csE'-�1 pPRES BORE <br /> )gWELL#_ PRESSURE GROUT <br /> 'Other. <br /> COMMENTS: / 6-orob-c faun ' <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING tiOLLOW STEM --� DIA,1 F BOREHOLE MULTIPLE CASINGS?0 YES , AO WELL CASING DiA:_ <br /> EXTRACTION Q AIR HAMMER/ORIVEN CASING THICKNESS' TYPE OF CASING: 0 STEEL - -VC ❑OTHER: <br /> Q VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL . TREMIE TYPE TO BE USED: AUGERS OSE <br /> POINT GROUT SEAL PUMPED:5Yes It NO (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> B AIR SPARGE , PUSH <br /> +SOIL BORING p HAND AUGER APPROX.BORING DEPTH 6OLTE0 TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER: <br /> 0 OTHER CONDUCTOR CASING PROPOSED7 /0 (if YES,list specifications here): <br /> COMMENTS- 45,0—vri0 <br /> NOTE: OFFSITE BORINGS RECfUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I herebycertify that t have prepared this application and that the work will ba done In accordance with San Joaquin County Ordinances,State Laws,and Rules <br /> and Regulations of the San Joaquin Courtly. Hamocrwrier or Iloansed agent's signature cerdfias the following:-1 cerrlry that in theperformence Ofthe'Fork <br /> for which this permit Is issued,f shell not employ persons sulljec!to WORKERS'COMPENSATION Laws of plifomla." Contra rsaons subject to b <br /> contracting signature certifies the foliming:'I cer6Yy Mal In the peftffnence ofthe work forwhich this permit is issued.I shell employ Pe <br /> WORKERS'COMPENSATION laws of Cahfonua." <br /> :C^AL/L'.3 f J 111kT1`^115P C70R 48s1Nt;?,k?QKpt `IFI ADVIINGEIFOR Iii t�REQGIRE0,44IP�l G&IPIVS <br /> Signed x—d'�� Tide/Company 57- 7.V.�CrwtrioNSL Y+,t,. Pr+ "'46ey <br /> Print Name" -1 AU G��Cr�OvirG Date 00 p <br /> DEPARTMENT USE ONLY -7 <br /> — <br /> AP9licabDn Accepted By Date Issued ate <br /> Grout Inspection By Date Final Inspection By / <br /> Destruction inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK E RECD BY DATE PERMIT I SERVICE RERUEST# INVOICE <br /> /230 1-13 Z Ine/z000 <br /> 3501 / <br /> nl�� ✓ 61c <br /> n <br />