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04/12/01 THU 15:47 FAX 510 6F^ 4141 GEO ATRIS OAKLAND <br />f L� <br />WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />��-�`'p'`A' • ENVIRONMENTAL HEALTH DIVISION (PHS-EHO) <br />W ��e.�Lt�(. 304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209r 468-3449 <br />ORIGINAL <br />UI/' j iIfi� <br />UNIT IV <br />' �lg�i G!J• �,usn91v <br />4&a7- !d - emea4c6 <br />NON.R FUNOABLI* egRMIM-EXPISEES I -Y-EAR FROM DATE ISSUED <br />Application is heraby rnade to San Joaquin County for a permit to construct and/Cr install the worts described. This application is made in compliance with <br />San Joaquin County Development Title, Chapter 9-1115.3 and the Standards ❑r sin Jo2quin County Public Health Services, Environmental Hcalth Division. <br />Assessor's <br />WELL Lncacion ISSd J-7 Ica' E. OZ Corral >"Jlgp Rd Cross Street �1a I H.,j)pL-j City Tri r Zip Pafcals <br />it/S'F.o� 99JAM ;6.,kde. L;4!5+ LIQ S rta.} rrdc.- r <br />PROPERTY Owner. WaS+ 5>c4 Srr;2s;,4im d:3+ Address City Zip_ Phone (f%V <br />qui cf Trae7 233• sig <br />C-57 Conttactor��cc _sips So,,,p�;n in�.Addresa 15104 S, sn + Sl-• City Ri�hMon� zip 71j2bq Li-* ✓r. lg2 Phonefl SiQ "—Lq� <br />Consultant/ Sub Carttra=ar Gia -„ie 3-4v x C S WaAk Address -101 lJn�S 51 city Ch I -,-J Lia* Phonatco�(,�3 <br />I'L"N Iter <br />GIS CooMinares: X Y Township Range Section <br />WORK TO BE PERFORMED <br />)(N>=W WELI ORING CPT, GEOPROHE, HYDROPUNCH, HANn-AUGER, OTHER-) Q DESTRUCTION (choose type oelow) <br />SOIL BORING s GmX-3 G—M—� CmA-� �dtit %=ri,,jy {e I,,b—krl, tri Q OVER -BORE <br />WELL# W) csmtu� yro,�p 4.o--+ B+inti^ IV IV D PRESSURE GROUT <br />-Other: wi ft—mlr P we �lku�+5 Se•r•o1�ng _ <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />Q MONITORING Q HOLLOW STEM OLA, OF 00REHOLE_J�L_ MULTIPLE CASINGS? D YES )(No WELL CASING DW <br />0 EXTRACTION 0 AIR HAMMrtRIORIVEN CASING THICKNESS M14 TYPIE OF CASING: 0 STEEL 13 PVC 0 OTHER: <br />p VAPOR p MUO ROTARY DEPTH OF GROUT SEAL_ A/ild _ _ TREMIE TYPE TO BE USED- Q AUGERS DHCSE <br />D AIR SPARGE PUSH POINT GROUT SEAL PUMPED: Q Yes I No (NOTE: MAXIMUM FREE -FALL DEPTH IS,30') <br />XSOIL BORING a HAND AUGER APPROX. BORING DEPTH 2s' ma . Q BOLTED TRAFrIC BOX or 0 STOVE PIPE <br />Q OTHER:_0 OTHER CONDUCTOR CASING PROPOSED? ( it YES, list opacifications here): <br />COMMENTS: LXrer.} W /. II fig Lji'il teles., 2110"" 61- 2S.' 4 i 15fall *aA'sp L Ola 0yc <br />yrown�la.+o1�.-All ae.tr<V t_/itL_ C- baLkf:llr j 01 Gew49A+:evu4- ul a fi'ertn}�Q; e. %llnui K _An&f 1,e <br />NOTE; OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br />hereby rortify that I have prepared Chia application and that the work wilt be done in attendance With San Joaquin County Ordinances, Stitt Laws, and Ruies <br />and Regulations, of the San Joaquin County. Homeowner or licensed agenrs signatuntt certifies the following= "I certify that In the performance of the work <br />for which this permit Is Issued, I shall riot employ persons aubjeet to WORKERS' C041PLONSAT70N Laws of Cati Conlractor's hiring or sub- <br />contracting slgnaturr certilfes the following: 'I cartrfy Morin the performance of the work Ibrwhich this permit is issrted, I shdll employ persons subject b <br />WORK/ RS' COMVENNS�SA77ON Laws or Calitomia. - <br />-'�rc MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />r ,fit <br />Signed x Title rl C Date <br />SEE SITE MAP IN UNIT IV WORK PLAN DATED <br />DEPARTMENT USE ONLY O� <br />Application Accepted I Date Issued ed <br />Grout Inspection By Date Final Inspection By Qate <br />Oestructlan InsRectlon By Date <br />COMMENTS I CONDITIONS: I :v_- G <br />ACCOUNTING ONLY: I AIDS ' ­-� J6 <br />PE CODES FEE INFO <br />AMOUNT REMITTED CHECKAICASH <br />RECEIVED BY <br />OATS, <br />ITISERVICE REQUES M INVOICE <br />StODS43$ <br />SR# <br />UNIT TV - 6/23/99 /sign Bkpg/MI <br />ze 3rtJc 6007: HI-31� ECVE99bG@z 00:bI 90K/Z1/ti0 <br />