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06/18/2002 le 26 2094683433 FIFTH FLOOR PAGE 02 <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION ("PHS-EHDr) <br /> 304 E. Weber, Third Floor, Stockton, CA., 96202 <br /> (209) 468-3450 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ,Application is hereby made to San Joaquin County fora permit to Construct and/or Install the work described This application is made in compliance with <br /> San Joaquin County Development Title Chapter 9-1115 3 and the Standards of San Joaquin County Public Health Services Environmental Health Division <br /> Assessor's <br /> IVELI-Locatlon 1001 E. (05E,MITE AVE. Cross Street RAYLOW AV.Gity MAKECA zip 95336 Parcel# 0413-240-03 <br /> PROPERTYOwner OARAKAp: 1N6. Address (iNOLLYIEW DR G,ty, PA1VVlt1E 5— it <br /> -. z,p 9 452 Phone# 9'�5— t I S 8 <br /> (.iz5) <br /> 57Contractor G-Rf IR-51TV W.Address 550 Howl: KOAD Ctty J4RT1"f1zrp2SS3 LIC#656401phone# 313 — 5600 <br /> RANCK0 R.Cr. (SIG) <br /> ConsuitantlSub Contractor RAMAfrF_ Eit{V Addr@SSPC13Ox 969 City VAIF[ Uc# S$S6 Phone054-32947 <br /> I <br /> IS Cowdinales X Y Township Range Section <br /> ORK TO BE PERFORMED <br /> NEW WELL I BORING(CPT GEOPROBE HYDROPUNCHI,HAND-AUGER,OTHER-) 0 DESTRUCTION(Choose type below) <br /> �E SOIL BORING a,Ct'T1}6, GPT-5 0 OVER-BORE <br /> D WELL# 0 PRESSURE GROUT <br /> 'Other <br /> .COMMENTS <br /> YPE OF WELL CONSTRUCTION TYPE CONSTRUCTION—SPECIFICATIONS <br /> MONITORING 0 HOLLOW STEM CIA OF BOREHOLE -INCL MULTIPLE CASINGS?D YES M NO WELL CASING DIA MA <br /> Q EXTRACTION Q AIR HAMMERIDRIVEN CASINGS THICKNESS NA TYPE OF CASING O STEEL D PVC D OTHER NA <br /> IROR p MUD ROTARY DEPTH OF GROUT SEAL TO ISO' TREMIE TYPE TO BE USED D AUGERS THOSE <br /> SPARGE PUSH POINT(fe t) GROUT SEAL PUMPED I Yes D No (NOTE. MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING LZ� 0 HAND AUGER APPROX BORING DEPTH 15 U-FEST a BOLTED TRAFFIC BOX or a STOVE PIPE IIIA <br /> OTHER CONDUCTOR CASING PROPOSED?_M0 (if YES list specifications here) <br /> COMMENTS <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMtTSI <br /> I hereby Certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances State Laws and Rules <br /> nd Regulations of the San Joaquin County Homeowner or licensed agent 5 Signature certifies the following 'R certify that rrr the performance of the work <br /> r which this permit rs Issued,f shall not employ persons subject to WORKMAN'S COMPENSATION Laws of Calrfornra" Contractors hiring or sub- <br /> ntracling signature certiFes the following '1 oerU the,performance of the work for whrch this permit is issued I shall employ persons subject fo <br /> WORKMAN S COP � -ricON Laws of Cahfo s" <br /> TZ.0" <br /> PPL.ICANToq CA a$ HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS <br /> AW x <br /> Title Datef � �r <br /> SEE SITE M I NIT IV ORK PLAN DATED s1.2010l <br /> dPA ENT USE ONLY jf�j <br /> !i ion Accepted i3 i Dale IssuBd 1 D Area <br /> App cat p Y <br /> root Inspection By <br /> Date Final Inspection By Date <br /> eslruction Inspect on By Date <br /> cOMMENTS 1 CONDITIONS <br /> FAG# <br /> OUNTING ONLY AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHFCK#1CA$H JE EDT BY DA E PERMITISERVICE REQUEST NUMBER INvOICE <br /> r <br /> 'UNIT IV 6/1/99/sign bkpg/MI <br />