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TYPE OF WELL <br />a MONITORING <br />I EXTRACTION <br />a VAPOR <br />AIR SPARGE <br />g-16-n_ BORING <br />I OTHER: <br />INSTALLATION TYPE <br />a HOLLOW STEM <br />I AIR HAMMER/DRIVEN <br />B MUD ROTARY <br />VUSH POINT <br />0 HAND AUGER <br />a OTHER <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE 1. 75 'IMULTIPLE CASINGS? a YES I NO WELL CASING DIA: <br />CASING THICKNESS TYPE OF CASING: I STEEL a PVC a OTHER: <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: I AUGERS IHOSE <br />GROUT SEAL PUMPED: a Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />APPROX. BORING DEPTH 50/ <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br />BOLTED TRAFFIC BOX or I STOVE PIPE <br />DEPARTMENT USE ONLY <br />Application Accepted By Date Issued Area <br />PA341-- 6-6?-uf-e-17 LLIP mcg <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS / CONDITIONS: r1A0 <br /> Date Final Inspection By Date <br />Date <br />WELL PERMIT APPLICATION flitRM <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES();t/ <br />/4* ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 -y k9 (209) 468-3449 LSZ<\ <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED /C)i;; <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in co lian ith <br />‹ s <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 />WELL Location 30 3 2_. E. i...Nterho 40/tcl Cross Street Stit 4-0.0 MC city SitereiCIOTN) Zip eiSIOF,5 Parcel# <br />204 <br />PROPERTY Owner pie.PAik) Sidki. Address 3032. E. kte;kyLoo R.8. City E71X-k-ta'3 Zip 95205 Phone# 1-64o —5-81(O <br />AdvAP•tele-4 Wei <br />C-57 ContractorfceoriothRONoke"thrti-iXiic•Address 4005 ha%) City Sitre-4/10 Zipqrafic Lic#0022.7 Phone# 41-L07 - /0-0 <br />A dilAtJte-a <br />Consultant / Sub Contractor GeVe4,11ROAiliw&hd- TAX. Address Stosila M /46302- City Lic# Phone# <br />GIS Coordinates: X <br /> <br />Township 2. N Range 6E <br /> <br />Section <br /> <br />WORK TO BE PERFORMED <br />i;VI(E/W WELL / BORING ( CPT, EOPROB-ZHYDROPUNCH, HAND-AUGER, OTHER*) <br />OIL BORING # <br />I WELL # <br />.DervInefion.)— Geo Kt <br />COMMENTS: <br />*Other: atet <br />I DESTRUCTION (choose type below) <br />uti2= <br />E <br />GROUT <br />Copi.pleft- r&-71/7—.) to Smr-roi-c...e. greq-ck__ . <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 done in accordance with San Joaquin County Ordinances, State Laws, and Rules <br />and Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: "/ certify that in the performance of the work <br />for which this permit is issued, I shall not employ persons subject to WORKERS' COMPENSATION Laws of California." Contractor's hiring or sub- <br />contracting signature certifies the following: "/ certify that in the performance of the work for which this permit is issued, I shall employ persons subject to <br />WORKERS' COMPENSATION Laws of California." <br />THE APPLICANT MUST CALL 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />Signed x (A.6, kr) Title <br />ACCOUNTING ONLY: AID# <br />FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT / SERVICE REQUEST # INVOICE <br />610i _ XC1 .4?—e' ,S. --rr f "2:- 7 ,1? 4-141 /-1 47-1`7`; SR# °?"/ e2S- <br />C-57 LICENSED CONTRACTOR MUST SIGN LICENSE &WORKERS' COMPENSATION DECLARATION <br />UNIT IV - 6/23/99 /sign bkpg/MI <br />Date /0191 <br />SEE SITE MAP IN UNIT IV WORK PLAN DATED: IZ Octobm. <br />09,7