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04/26/2000 00:23 20946634 FIFTH FLOOR � ORIGINAL <br /> � <br /> WELL PERMIT APPLICATION FORM UNIT IVC <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES �1 <br /> 'J ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E.Weber, Third Floor, Stockton, CA., 95202 <br /> (209)4683449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work descrmed- i nls application h made in cornpllance with <br /> San Joaquin County Development Title,Chapter 9-1115,3 and the Standards of San Joaquin County Public Health Services, EnvironAmeentoal Health Division. <br /> /n�' /, 2Y`t-070'00 <br /> WELL Location �1 �� / <br /> 2 36(�S 5• SCA{ Ee Ko.Dross Street City [tdLLp 95347 Parcet# <br /> PROPERTY O.vnerTro r`•� Address23Llos S. .fgnl'�. �L •City/41K/Nawit Zip 93-3&7 phone#2Z'r-Y4f-ZGrj3 <br /> C-57Contraaor Addrass3Z33 -jr. lcl #D CityLZip9flyL Lie#SSY5Y97Phone0- Lae-7274 <br /> Consultant Sub Contractor 5FldZ1A-(rrnAir1++A( Address3 7kAp- IW Cltyzuj.&•J^ ' LIdF&102- Pnone#E& <br /> GIS Coordinates:X .Y .Townsbip 3 AILS Range SEAS-1-- section Z9 <br /> WORK TO BE PERFORMED <br /> XNEW WELL BORING(CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER-) a DESTRUCTI O(ER-BARE choose type below) <br /> p SOIL BORING# 0 PRESSURE GROAT <br /> .VWVELL# W- <br /> .oil, . ^A <br /> COMMENTS; / /kontfen N1c(1 S IK J, <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS „ <br /> �JINIITORING 'AHOLLOW STEM DW.OF BOREHOLE 1r MULTIPLE CASING57 p YES *NO WELL CASING DIA:Z <br /> Tl EXTRAC'T'ION 0 AIR HAMMEWORNEN CASING THICKNESSC�l�•�ID' TYPE OF CASING: p STEELVC N OTHER: <br /> VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL /6 TREMIE TYPE TO BE USED: qAUGERS *OSE <br /> PAIR SPARGE p PUSH POINT GROUT SEAL PUMPED:-3LYes U No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING p HAND AUGER APPROX.BORING DEPTH W $OLTED TRAFFIC BOX or []STOVEPIPE <br /> a OTHER: n OTHER CONDUCTOR CASING PROPOSED7 /V6 (N YES,list specifieatlons here): <br /> COMMENTS" <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby certify that I have prepared this application and that the work will be done In accordance with San Joaquin County Ordinances,State Laws,and Rules <br /> and Regulations of the San Joaquin County- Homeowner or Ilcensed agsnfs signature cenitwa the following: -1 cerdry that in the performance of the work <br /> for which this permit is issued,I shell not employ pemons subject to WORKERS'CO41PENSATION Laws of Cdlifpmia." Contractor's hiring or sub- <br /> contracting signature certifies the following:"I certify mal in the performance of the work for which this permit is issued.I shelf employ parsons subject to <br /> WORKERS'COMPENSATION Laws of California." <br /> <CAL r, jJ�). k-T�11Y kSP CTOR°48fYSipRE{�j fiRffiYN ADVANCE . ISLt7 EQ,F7IREU;INSPCxi3�O S <br /> Signed GllGGet�v/ih el Title/Company °kcL Ma7N5 s$I9R �n�einh�r�nh� 1r c <br /> n -/O-Do <br /> Print Name � H er ,2T-C qty Date <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Issued (hod Area <br /> Grout Inspection By - Date /� Final Inspection By Date <br /> Desiraedon Inspection By Date / <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT RE=CHECRECD BYDATE PERMIT I SERVICE REQUEST 0 INVOICE <br /> Ioi 232 c 7.1SR# Z3 OG <br /> 1/1&/2000 <br />