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04/20/2000 06:23 20946034' FIFTH FLOOR PAGE 03 ��z <br /> • • ORIGINAL c <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E.Weber, Third Floor, Stockton, CA., 95202 <br /> (los)as8-3aa9 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct andlor install the Wark described. This application is made M compliance with <br /> San Joaquin County Development Title,Chapter 9-7115,3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br /> I Assessor' <br /> cas <br /> WELL Lotion 2 3-70( 5, Sc.4c,Fe /rtfid Cross Street City QI U•tAIdo/L Zip 95367 Parcel# <br /> PROPERTY Owner 3AMC pTP act cess23"10) S �eA+tL Fe Qrl City c.n ipq�g7 Phone#? <br /> C•67 Contractor U:rsl Nrz ftxl- Jlddress iZ33�4rnu*1�.S.k-t3 City Zip9574L Lick 447 7 Phone# /L l"7276 <br /> Consultant t Sub Contrectars Er4rt Sn r >;rv+.sl Address 3otT K:L; c 1�1+=klW Clryp.>„dr,.1.-doN,LidF 4(UZ Pnone#� 8fcl-Okp�_ <br /> GIS Coordinates:X ,y..Township3 $ov� Range q E&J r Section Z y <br /> WORK TO BE PERFORMED <br /> XgEW WELL I BORING(CPT.GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) G DESTRUCTION(choose type below) <br /> G OVERBORE <br /> JI <br /> SOIL BORING — G PRESSURE GROUT <br /> 'Other. n <br /> COMMENTS: 1 ^A,0-,Jo <br /> .(Lj <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS , <br /> MONITORING �HOLLCW STEM'—tea DIA,OF BOREHOLE E" MULTIPLE CASING-Z7 0 YES NO WELL CASING DIA; <br /> U EXTRACTION G AIR HAMMERtORNEN CASING THICKNESS StH. 40 TYPE OF CASING; G STEEL 'PVC G OTHER: <br /> G VAPOR G MUD ROTARY DEPTH OF GROUT SEAL__Zb_L_TREMIE TYPE TO BE USED: jrAUGERS Nt OSE <br /> G AIR SPARGE G PUSH POINT GROUT SEAL PUMPED:)WZes G No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> G SOIL BORING G HAND AUGER APPROX.BORING DEPTH `,0 I `K50LTE0 TRAFFIC BOX or G STOVE PIPE <br /> G OTHER: G OTHER CONDUCTOR CASING PROPOSED7_tZQ_(if YES,list specafcations here): <br /> COMMENTS: — = ( +u Ljol Ln,,S <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby certify that I have prepared this application and that the walk will be done In accordance with San Joaquin County CIdinanrms,State Laws,and Rules <br /> and Regulations of the San Joaquin County. Hamcanner or licensed egartfs signature certifies the following: -1 cerdryrhat in the performance of the work <br /> for which this permlr Is issued,I shell not employ persons sutyeci to WORKERS'COMPENSATION Laws of Califomla." Contractor's hiring or sub- <br /> contracting signature certifies the following:•t corb'fy,thal In Vee porfannance oftho work for which this permit is issued,I shall employpersons subject to <br /> WORKERS'COMPENSATION Laws of CaMornia.• <br /> EALL,THlyN11Y11SPCTOR 48fYYAINLTitRS�1N ADVAKI_GE1fiOR,���spREG1(7IRED`IN6Ptl�GSIp�S <br /> Signedx � TitlelCompany ProJY7-4- , SBl6R.7vr�c.rw. A� 7-nc <br /> Print Name UK RUCAlIvrlDvL-�y. Date 7-10-po <br /> DEPARTMENT USE ONLY Appliication Ar7ptcd By Date IssuedGrout Inspection By DateFinal Intipecto7Byjo 0/ <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK i RECD BY DATE PERMIT I SERVICE REQUEST It INVOICE <br /> 23.4 -7 1 <br /> 1.11812000 <br />