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03/22/2002 11:43 2094683433 FIFTH FLOOR PAGE 03 <br /> }}!: } WELL PERMIT APPLICATION FORM UNIT IV <br /> (ICAs ? i _ <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> 02 MAR ' ENVIRONMENTAL HEALTH DIVISION•(PHS-EHD) <br /> 304 E. Weber, Third PIoor, Stockton, OA., 95202 <br /> (209)468-3449 <br /> NDN-ReFEJNOABLF-PERMrT_EXPJRES 1 Yi=PAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit ID construct and/Or install the work described. This application is made In compliance wi h <br /> San Joaquin County Devetopment Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,ErMironmerital Health Division. <br /> Asseuots <br /> _130 S, Lt1� dao LIL4 Cross Street{d QSkloim. Cil rp� Parcehl <br /> WELL Location f U. <br /> y S i"Q� T Sz0 <br /> PROPERTY OwneT_�4AU>1G�au��fn(e-Address Cid. &Y)` City A 0. zip SIf5lophoneo <br /> �} ( r Op <br /> C-57 Contractor &;6C1Jwa.V-d Address f': 0. 8v-X 336 CityRio 6—>6—Zip s7j Lie#7104 Fholai! 551y" <br /> 3 3o DIN <br /> SSo t wr�w�r <br /> GonsulEar�tlSub ConkrHctor l � t1111i1'uy�... • Addressor, �.rlc >`7r� _ City LiciF -7 <br /> GIS Coordinates:X_ Y -Township Range Section <br /> WOLRK TO BI~Pj FORMED <br /> 'A,NCW WELL I BORING(CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER") Q DESTRUC ON(choose type below) <br /> [],SOIL BORING 0 U OVER-BORE <br /> WELL 0 W -I --pt w - o PRESSURE GROUT <br /> 'Other. <br /> WmmENTS: <br /> TYPE*OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIOtdS <br /> D MONrrORING `,K HOLLOW STEM DIA,OF UOREHOLE-� MULTIPLE CASINGS?0 YES �NO WELL GASIING DIA: <br /> a EXTRACTION /0 AIR HAMMEMRIVEN GA8tNEG 7NICKNESS [) TYPE OF CASING: 13 STEEL X(PVC a OTHER: <br /> U VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL SO r TREMIE TYPE TO 8E USFD: JlFkUGERS y OSE <br /> AIR SPARGE p PUSH POINT GROUT'SEAL PUMPED:xes. Q No (NOTE: MAXIMUM FREE DEPTH tS IV) <br /> SOIL BORING E HAND AUGER APPROX,BORING REFTH $S! BOLTS0 TRAFFIC BOX or p STOVE FIFE <br /> p 07HEI2; _a OTHER CONDUCTOR CA-SING FROP4SEl3? (if YES,list towificalions 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 dome In accordance with San Joaquin County Ordinansas,State Laws,and Ides <br /> and Regulations of the San Joaquin County. Homewmer or Eicensed agent's signature eerti5es the following:`l certify that irn the pm'fornsanee of the work <br /> for which this permit is issued,1517011 riot employ persons subject to WORKERS'COMPF-NTAT10N 44ws of Cali€omla." Contractor's hiring or sub- <br /> oarctmuting signature certifies the fallowing: "l certify that in the perforrtr&rtce of the work forwhich this permit is issued,l shall employpersons subject to <br /> WORKERS'COMPENSAT10NLaws ofCalifomia." <br /> F3 . / 0r -. <br /> Sig ncd v Title Date 3 17- 0� <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED: <br /> DEPARTMENT USE ONLY <br /> Application Accepted By^�`d . '[.1� �- Bata Issued :a(- c> -.)-- <br /> Grout Inspection By Data Fnal inspection By Date„ <br /> Desbuction Inspectil"By Data <br /> COMMENTS I CONDITIONS: <br /> FACOOUNTING ONLY: AID# <br /> CODES FEE INFO AMOUNT REtUI-rTED rHECK# REC'b BY DATE PERMIT I SERVICE REQUEST 0 iWOICi~ <br /> L ter-. <br /> UNIT rV-6/23J99/sign bkpg/MI <br /> j <br /> I <br /> 'rl WOi`I� WYrS�S= l L 6'fa6 t-�O-Z l <br />