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\ REC'O BY DATE
<br />
<br />PERM( / sapvic.F INVOICE
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<br />`; TX.
<br />
<br />517,2 7/
<br />
<br />ACCOUNTING ONLY: Aloe
<br />FF7E-GOr)ES FEE INFO AMpLinJT REMITTED HECK 0
<br />
<br />,05/22/00 15:24 V209 465 7244 PORT OF STOCKTON
<br />05/15/2000 MON 11:31 FAX 916 4101 V W DRILLING INC
<br />
<br />05/15/00 10:18 azo 9 4135 7244 PORT OF STOCKTON W DRILLING INC
<br />U002
<br />10002/002
<br />21002
<br />WELL PERMIT APPLICATION FORM UNIT IV
<br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES
<br />ENVIRONMENTAL 1-15ALTH DIVISION (PHS-E)
<br />304 E. Weber, Third Floor, Stockton, CA., 95202
<br />(209) 468-3449
<br />ittgatifr1iNoA.3LE PERMIT EXPIEUROM OATS issUO
<br />;,FF
<br />,iIe.a Linn Is neroby made to Ssn Jaor,4win County for a permit to construnt and/or lesteu the we* described_ This application lo ril de In complisnco with
<br />s2n Aia quir, county Development Title. chapter la-111-5.- and the Standard of Sr Joacioin County Publlo Health Services, Sn.ironrnental Health Division.
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<br />,Assef.sar's
<br />WELL. Location C Cross SUS ),5 • le4 City Srec kic',1 71p 7-?-- '-'1 parcel-4..
<br />P'6`4 e1----d fr
<br />PROPERTY °Vint? A-71'7f- V7
<br /> jr Address i-V1C J 11X l'Al".17cA -c.:7; City Sn'711-7tV1 zlp, ‘;',7-LrV phor,,14, 67 - L"...:11 i! r
<br />Address /-361 )C -) / ,..City g:13 15-1-1-_ zipc7iT-7/ t_i 7-,-7(1/Phene,-,7=7.-.375/--;',7(5-
<br />C-7 contrictv
<br />Ate.res5 City_ Lid: Phanag
<br />Co rwialtant (Sub Contractor _
<br />Section_
<br />nisc„L ,:x_______,___4197.5'8.31 y_q_elifl. 7_331/ . Township TIN
<br /> ___---
<br />Ra 9nge _A ,; Lt"
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<br />-rypF OF WELL p4STAI____,FICN.--r-LT-t CONSTRUCTIOPPICATIONS m" (N COMMENTS:
<br />X HOLLOW STEM DIA. OF et:IRO-K:1LE 'Pv.' MULTIPLE CASINGS? El YES y1\10 WELL CASING DIA: 491 P"---
<br />0 ExTcitoN n AIR I-LAMMER/DRWZN CASING THICKNE5S-V-1i- 051 TYPE 05 CAVNG: 5 STEEL A PVC E OTHER: XMONITORINO
<br />11 VAPO 5 M110 ROTARY DEPTH OF GROUT SEAL TREMIE TyFe TO 13-E USED: 0 AUGERS HOSE
<br />R.
<br />5 AIR SPAR GC 0 PUSH POINT GROUT SEAL PUMPED: D Tao 5 No (NOTE.; MAXIMUM FREE-FALL ID EPTH Is 301
<br />5 SOIL BORING n HAND AUGER APPROX, 6ORING DEPTH 0,6 ' zsoLTE0 TRAFFIC BOX or U STOVE PIPS
<br />n OTHER: _,.J3 OE__ CONDUCTOR CASING PROPOSSD? ( if YES, 5st speicItications here);
<br />THR
<br />COMM ENTS. Di!.51-AtC776/3 /1141-53 ._4.. ort. c _5"-leeral./2e. lo x _2 ,:t4-4 4,19 ,.,77,-, it•t- ..
<br /> _
<br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS
<br />I herg.try =ivy tha7Tra,"ie T.Faied lnis aPPnc-OvIarvi !Jiat the work vItIi be dung in accordance With Zan Jasquin County Ordinances. State Laws, ana Ruies ----------.....---
<br />and Regulations of ;Int Sari Joaquin County- Hornikowner or lnsesl sgent's sIgnature cartifie the following: ll certify, that in the pufonmance or th work
<br />for which ;his 1:!wrIII Is isgLieci. 1 shall nOf employ pirSons subject to
<br />WOPKERS" COMPENSATION Laws of California." Controctor's Airing or M:ti-
<br />conlraCting s'ignalure zerfifiea the followIng: '1 certify that in Vis perfprmQncc ol thc work for which this permit is issued, I 0011 amploy parsans subject to
<br />ALL TNE UNIT 1V11•IPOTOR 4F3 WORKING HRS INI ADVANCEO FR ALL REQUIRED INSPECTIONS. YVRKEP5' V7MPENSATION Lows or California:
<br />TilltiCompany i.4.,PV/h411
<br />Sired 1
<br />Print Narne
<br /> _Clatt az)
<br />--AN.J.Q1,11:[LAAO_'1FAI- A E ,,,,Z.X.:.3 :,:.7,-':A..'nl."'- 7;71,2illz?,0-1
<br />----___.—
<br />DEPARTMENT USE ONLY
<br />Applirati.zn Ac=pted Iiiy___Z-2.e7 -7,-0--e-/ ----,--- Dale Issued .S.- 3 - -C-C) Are_ ( ) 7
<br />Grout Impeders By t).- Date Final inSpectIon By 0 tc
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<br />-
<br />Destnictien InCptct3on By ...! Date 5/2.6 /op - 3 m tea i des 74--vye
<br />,
<br />Imo
<br />co MMENTS I CONDITIONS; ( f.;.--- ' /,-)- 0-, ,.,_ t-c,"%. t9
<br />VitioR.)< 70 5g PERfORMED
<br />0 NEW INSLL / BORING (CPT, GEopptoSE.14YDROPUNCH. HAND-AUGER, OTHsr)
<br />0 SOILEORING -4t___....,..-
<br />5 LL 0 h e.oer ,
<br />. Othe r ,PC_SfrifAcTic19 .,,r.r • pr -f or 2 .
<br />DESTRUCTION fchole type below}
<br />OVER-BORE
<br />.PRESsURE GROUT
<br />
<br />2_
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