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06/18/2002 10.26 2094683433 FIFTH FLOOR PAGE 03 <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 /> (209) 468-3430 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Apphcalion is hereby made to San Joaquin County for a Permit to Construct and/or install the work described This application is ma <br /> de 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 DIv s on <br /> ClT`t OF MIANrECA STREET <br /> ' WELL Location EAST OF IDI RAYLOW AVP-, Assessors <br /> C t r Y o U- M A NT&1;A cross street C�Y vf-."E"'"c�' �'M1A N t CCA Zip 95_ 33 6 ParGef�v <br /> PROPERTYOwner PVDLtC. W0jttcS_t tPr Addressll)01 W'CENVES, $1. <br /> city MAHT CA <br /> zip 4 33 Prtone# -1f 0 <br /> 1C-57Contracior�E&G- (N`SIIVt INC Address 950 ROWE 110AO cityRTI�� ZIp945x3L1c#65b40�Phone#_3 l3 92s) <br /> �/Sub Contractor RA MAGP- EAIV, Address -0 a0 8CI Cit RG t�A C1�4 ' (9116) <br /> „5 <br /> -�' x 6 YhV 1l:t>� Lic# 156 Phone# 351-3150 <br /> GIS Coordmatos X Y —�,Township ,Ran9a-__ Section — <br /> WORK TO BE PERFORMED <br /> Q NEW WELL l BARING(CPT GEOPROBE,HYDROPUl HAND-AUGER OTHER') 0 DESTRUCTION(Choose type below) <br /> —1 <br /> SOIL WELL BORING# CPT Q OVER-8081= <br /> Othor 11 PRESSURE GROUT <br /> COMMENTS <br /> TYPE OF WELL CONST RUCTION TYPE CONSTRUCTION SPECIFICATIONS <br /> 10 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 1-(Nt N MUL1 tPLE CASINGS?0 YES 0 NO WELL CASING OIA NA <br /> U EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS N A TYPE OF CASING 0 STEEL a PVC I)OTHER h A <br /> POR 0 MUD ROTARY DEPTH OF GROUT SEAL,D= ISO" TREMIE'(YPE TO BE USED p AUGERS (HOSE <br /> SPARGE j PUSH POINT (CP;) GROUT SEAL PUMPED 1 Yes I)No (NOTE: MAXIMUM FREE-PALL DEPTH !S 30') <br /> SOIL BORING 0) IZ HAND AUGER APPROX BORING DEPTH 15 0-F 15 tT 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE N A <br /> OTHER CONDUCTOR CASING PROPOSE07 140 (if YES, hst sp ifrcadons here) <br /> I r <br /> OMMENTS <br /> NOTE. OFFSITE BORING REQUIRE ACCESS OR ENCROACHMENT PERMITSf <br /> Whereby certify IhaI I have prepared this apptimon and that Ibe work will be done in accordance with Sart Joaqwn County Ordinances,Stale Laws,and Rules <br /> and Regulations of the San Joaquin County Homeowner or licensed agent's signature certifies the Wowing It certify that in the performance of the work <br /> &rwhich this permit is issued I shall not employpersons subject to WORKMAN'S COMPENSA770M laws of Californrs" Contractor's hiring of sub- <br /> ntracting si nature certcries the following 'I ceelrfy that in the performance of the work for which this permit is issued,I shall empJoypersons subject to <br /> ORKMAN COy1PENSATJaN Laws o!Cakfomia- <br /> APPLICANT MUST A 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> �gned Title <br /> SEE SITE MAP IN UNIT IV WORK PLAN. DATED s z 6 o I <br /> PARTMENT USE ONLY <br /> 1plicatmriAccepted By Dale Issuedb � _ <br /> —Area <br /> Grout inspection 13 Date Final Inspection By Date <br /> struction Inspection 8y Date_ <br /> MMENTSICONDITIONS <br /> KO) <br /> G ONLY AIOV FAC# <br /> FEE INFO AMOUNT REMITTED CHECKEXASH RE EIV D B D 1= PERM3Tls$RVICE REC]VEST NVNiBER INVOICE <br /> 8 ARA l <br /> UNIT IV- 6/1/99/sign bkpg/MI <br />