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e4/2B/2000 08 23 2094683433 FIFTH FLOOR uo))) 11D AGE 03 <br /> U D <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> 5. SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES D6; <br /> V30 ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E.Weber, Third Floor, Stockton, CA., 95202 <br /> (209)468449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Appikaoon is hereby made to San Joaau+n County for a permit to construct andfor install the work descried This appi—tion is made in compliance with <br /> San Joaquin County Development True,Chapter g717/n5��,3 and the Standards of San Joaquin County Public Health Servlces Environmental Health Division <br /> �o(o� S ter► I~e K[t crossstraet Cay&jCfjj6,r,_Ak Zip 95347 Pa Assessor <br /> WELL Location �J ` <br /> ROU Addressz S S. r fG �� City/4utnaa�l�_ ip YS_ 347 Phone#Zc4-Y6f Zdyj <br /> PROPERTY Owner ro ' <br /> +� i`6 C pa,Ky�,[L.,I�zipFS74L LrctFS3Ys757 Phone#446 6-3e-7Z7(.C-67 Contractor Gks�"A W, A ddress„3Z33 f tz�c+r. �Y <br /> Consultant I Sub Contractor'a -'1KkreFULVC4-rt1, Addres 7k, kv Clry !+ L&- Llc#4r!�L Pnane#�!4&�I�yoy <br /> GIS Coordinates X Y Township 3 5A24V Range q E-AS Section z�/ <br /> YZRK TO BE PERFORMED <br /> Np PR <br /> Etr+1WELL I BORING(CPT GEOPROBE,HYDROPUNCH HAND-AUGER OTHER-) p DESTRUCTION(choose type below) <br /> SOIL BORING 0 0 ER <br /> „'�']tYELL# �PRESSSUREURE <br /> GROUT <br /> •Other <br /> COMMENTS /'iLontfa re W�� IKA• <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION 5P>=C1FiCAT10NS <br /> W <br /> ITORiNG� �HOLL04YSTEM � DIA OF=80REHOLE rMULTIPLE CASINGS?p YES O WELL CASING DIARACTION a AIR HAMNIERIDRIVEN CASING THICKNESS ds y�TYPE OF CASING p STEEL �1C );1 OTHER <br /> 13 VAPOR Q MUD ROTARY DEPTH OF GROUT S�aL 7REMiE TYPE To BE USEDAUGI=RSiOSE <br /> t]Alii SPARGE 0 PUSH POINT GROUT SEAL PUMPED Yes 13 No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> p SOIL130RING p HAND AUGER APPROX BORING DEPTH. y&4 - OLTEF TRAFFIC BOX or p STOVE PIPE <br /> 0 OTHER. n OTH CONDUCTOR CASING PROPOSED7__.&D (If YES list specsfieations here) <br /> COMMEW117s• o W_ 'y 0` G41 <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hemby certry out I have prepared this apptroativn and that the work will be done In accordance wrill San Jnaquul County Ordinances State Laws and Rules <br /> and Regulatiana of the San.loagt8ri County Homeowner or deemed egerwe sr@natum cefuries the f06ovnngt-1 eeitKy that In are perfyor"Mme of tare work <br /> for which thc9 permit is issued,l shat!not&nW0YPe1`=WS Su4f W to WORiKERS,CogfPENSATION Lays of Attfornim" Contractor sshiringor ssub- <br /> aoMmdmg signature osrWias the following-`f aarsfy Mal In Me Perfarmarm of the work for which MIS permit os issued i shall erripfaype SU1ea <br /> to <br /> mmjOERS COMPENSA77ON Laws of CaffibMI.' fiR "IN ADS►J 1St o t- f=f 1R�D;�i PE l�Ns� <br /> i *tLem—wo. + P�CTOR�4$4��r <br /> Signed x <br /> Td1elCurnPany..�'a�cc-) /+'iGOhA�� S$10R-- �h�CrH�ati�-ohl �+4 <br /> PltntNstne r *t Data Z jt�-Oo <br /> DEPARTMENT USE ONLY &ION <br /> Date issued `f �a <br /> /�pp�ahon AQoepbed 6Y Date <br /> Grout Inspection By Date Final Inspection By <br /> Destruction Inspection By Date <br /> COMMENTS l CONDITIONS <br /> 11NT1NG ONLY AID# AnL <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK if RECD BY HATE PERMIT I SERVICE REQUEST It INVOICE <br /> 10 Z32. Z3 ftbl0 <br /> 1/18/2000 <br />