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O MONITORING 9 EXTRACTION 9 VAPOR 9 AIR SPARGE NycOIL BORING 9 OTHER: 9 HOLLOW STEM 9 AIR HAMMER/DRIVEN a MUD ROTARY '94USH POINT 9 HAND AUGER WELL PERMIT APPLICATION FOIR,,O.P.-. .. t:ipr it SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION ("PHS_-EHD1Sksp 0 304 E. Weber, Third Floor, Stockton, CA., 06162k )A.,, , 2 1999 (209) 468-3450 '-'-).,'-':-,.,-- , '''f/EA/7-A .-- ,l' c., -.it /.../z. 4-ALTH NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. .1 A .,....; Assessor's WELL Location 114S IV. vie kuv- /hit: Cross Street S• ZIrOCO/A) City 57riaaeiv Zip 615440 L- Parcel# PROPERTY Owner Mr. 6,-11 CiA#11144JOAddress r 0. eox Z 4)30 city Each zip_415-2// zpftr,e# (20`1) 34 - 1254, 0-57 Contractor Ar:h4ViCea ClifttirrOt-Ptildress 406 6.), ti)i keh) 'if/ - C - City 50-k4n-% ZIPISOW Lic# 6802Z7Phone#1P9)10-100(0 r Consultant / Sub CoatractoriA60,40/4/460C/JtilseCAI-Address 401;5-/vP kw idql,) Ill • City gitl_kirri, (..it 68C12 7 Phone# 462 - /al 6, --.,..._ GIS Coordinates: X Y , Township Range Section GEOPROBE, HYDROPUNCH, HAND-AUGER. OTHER') isia 14STRUCTION (choose type below) —BORING # C a OVER-BORE a WELL # i a PRESSURE GROUT <-- _ 'Other Obv-h04)-S 1.1i. 11 roe-7-5rozi---W —sv Ct- 9 rActe uy ix-sio,tc, LE4.4k- 5 /a r‘e- (" ' COMMENTS: A j rn-wiiki t.,-. 0,7/ 6E- ikf . iii`Ze4 - TYPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS "Cr DIA. OF BOREHOLE 2-iiVel-IMULTIPLE CASINGS? 9 YES 9 NO WELL CASING DIA: 0( IRENE TYPE TO BE USED: 9 AUGERS S tr4 EAL ;DEt +1.- nal /4 'TYPE OF CASING: 9 STEEL 9 PVC 9 OTHER:_ws; ED: a Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') --"" EPTH - a BOLTED TRAFFIC BOX or 9 STOVE PIPE (11) CONDUCTOR CASING PROPOSED? ( if YES. list specifications here): COMMENTS: A./0 Weil cot.) sty 041102 re pi T bee-ink/5 .140 SO ri-ae-e— 9 cfrzie beA;40.,•1' ‘,tk r .541v' j , NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS1 hereby certify that I have prepared this application and that the work will be Cone in accordance with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: "/ certify that in the performance of the work for which this permit is issued, I shall not employ persons subject to WORKMAN'S COMPENSA770N Laws of California." Contractors hiring or sub- contracting signature certifies the following: 'I certify that in the performance of the work for which this permit is issued. i shall employ persons subject to WORKMAN'S COMPENSATION Laws of California' THE APPLICANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. Signed x P 74.44-€44A ("1 61i) Title STAFF ec /cyst Date I SEE SITE MAP IN UNIT IV WORK PLAN. DATED Og/17 DEPARTMENT USE ONLY Date Issued 045 ci Final Inspection By Date ACCOUNTING ONLY: I AID# FAC# PE CODES FEE INFO AMOUNT REMITTED CHEC6CASH I RECEIVED BY DATE I PERMIT/SERVICE REQUEST NUMBER INVOICE I -C-O/ I 1 ,e - /2-7 / 2.- 1 /-1-( V SRO' C'249 441-1 1 UNIT IV WORK TO BE PERFORMED 9 NEW WELL / BORING ( CPT CASING THICKNESS DEPTH OF GROUT GROUT SEAL PUMP APPROX. BORING D Application Accepted By ktkAA-1,-e- Grout Inspection By 4--iii4kAe-a Destruction Inspection By COMMENTS /CONDITIONS: Fik.fre‘r, 514n-1-et (5A r ASrAtt_tui.ct$i lebl•wt." us-rILDP Date €71-1c Area f Date ,-13 UNIT IV - 5/99 /MI