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04/26/2000 08 23 2094563433 FIFTH FLOOR PAGE 03 �f <br /> WELL PERMIT APPLICATION FORM UNIT IV g <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES C(ObFCD:) y <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 4654449 <br /> NON-REFUNDABLE pER1NtT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ApplEcaCon is hereby made to San JoaQurn Caun[y for a permit to construct andfor install the work descried This epprirabon is made incomplianoe with <br /> San Joaquin County Development Title,Chapter 9-1115 31 and the Standards of San Joaquin county Public Health Services Environmental Health DivisionWELL Ltxabon <br /> .�3'TO( S. SG„{�FC_ d Cross Street City Jot 14_1 6r Fl Ztp f53G7 Parrmt#2_Yr- <br /> p(0p— <br /> � Phon <br /> PROPERTY Owner eD(L <br /> C-67 Cantraaorl+)esLHaz IA,k -- - J�ddress323�1:Izisenc� 5.>le _CrtyRar.leCo��_zaYS75/Z L1d#j6447q Phone#9lGSG!-7176 <br /> Consultant ISub CorttraderSEco�t3K�crna�t 1 Address 3&ci ktA-cg1I'-W Cltye,. L 41VZ Pnone#�I/G <br /> GIS Coordinates X Y Township 3 Sn,.,)kjRange oaf Section <br /> WO RK TO BE PERFORMED <br /> >=W WELL/BORING(GPT GEOPROSE,HYDROPUNCH,HANG}-AUGER OTHER-) d DESTRUCTION(choose type below) <br /> SOIL BORING p OVERBORE <br /> �eNELL# — p PRESSURE GROUT <br /> 'Other <br /> COMMENTSo�.#o <br /> *PEOF WELL lHSTALLATION TYPir CONSTRUCT{ON SPECIFICATIONS , <br /> ITORING ---� -KHOLLOVV STEM' � DIA ]F BOREHOLEMULTIPLI`CASINGS713 YES NO WELLCASINGDIA21RACTION Q AIR HAMMERIORIVEwN CASING THICKNESS ST-H t-t-D TYPE OF CASING Q STEEL `%PVC p OTHER <br /> VAPOR C MUD ROTARY DEPTH OF GROLET SEAL 1 EZ! 'TREMIE TYPE TO BE USED ,6UGERS WOSE <br /> p A1R SPARGE p PUSH POINT GROUT SEAL PUMPED Ayes 0 No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING p FANO AUGER APPROX BORING DEPTH `1D' 11�50LTED TRAFFIC BOX or [I STOVE PIPE <br /> p OTHER^ �OTHER CONDUCTOR CASING PROPOSED? fes_(if YES Gst specifications here} <br /> COwEHTS• — — 'M On ,S <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby certify that'have prepared this application and that the mark vd]be done In accordslnce whh San Joaquin County Ordmanaas State Laws,and Rules <br /> and Regulstians of the Sacs Joaquin County Homeowner or gtansed agents stgnaWre eentftas the fokw ng'"7 eer[lty that!^tfre performance ofthe work <br /> for whreh ftS p&rMft fs issued,!shell not einpfoy persons st cct to wt7RKERS'COIHPENSA710N Laws of Califomra" Contractor sob ct Iv nng or b- <br /> contrachng signature com las the fallowing "I eertfy Mal In the porfOrmat of rhe wo+k for which this ptsrrn,t rs issued !shag ernptaY Pe J� <br /> tNORKERS COMPENSATION Laws of CBhfomra" tfWIN ADVA.'RCSP9.4 kkf__ WRED, 061 <br /> 4A JW I kT `p E%rTOR !48f1H E ` <br /> Signed x TIt1elCompany vrt'}Mpr2,•e• St z 7x`Mcrna � <br /> PnrrtTEatne Auc �erlevlT>r pate <br /> DEPARTMENT USE ONLY C] <br /> Date Issued <br /> AppriCebon Accepted By <br /> Date Final Inspoctian By Date <br /> Grout Inspection By <br /> Destruction inspection Ely Date <br /> comilgNTS!CONDITIONS <br /> UNTING DNLY AIDIi <br /> PE CpDES FEE[NFO I AMOUNT REMITTED CHECK 4 RECD BY 13ATE PESiM1T 1 SI=RvtcE uE3T AE INvOICE <br /> 27,3� ^T- y <br /> 1/18/2000 <br />