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@/28/2@@@ 08:23 2094683433 FIFTH FLOOR PAGE <br />I ORI N7\65 <br /> <br />WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />Application is hereby made to San J03qUirl County for a permit to construct and/or install the work described. This application Is made in compliance with <br />San Joaquin County Development Title, Chapter 9-11152 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />Assessor's <br />WELL Location 2-3505' C. Ce.Aitt. Pt. Cross Street City (kv-u-LnAk Zip 536.7 Parcelit 2-'0'070 -COL <br />PROPERTY Owner -3-kA4k-^ PGLA•k-oirt_ Address 23 51.2S- Fe City AeroAk. ,zip 9630 Phone) 83E? - 7543 <br />C-57 Contractor WesV Address 3 2-3 3 1--;tz6z.-40 R-c) tc-L3 Citylwko Zip i'.5791- Lic#554197C7 Phone# 6,3B -7 Z72_ <br />Consultant Sub Contractor S EW2. vur Address "01.7 k: 1 qa,e lev <br />GIS Coordinates.. X Y Township 3 Range ci E-01-5 ) Section Z 4i <br /> Lic# Prione#W6 8."/-0Y 0t) <br />UNIT IV <br />w#YA <br />"Other: e0.--,.^5 f_s (di "AA+ cicA•7 <br />S <br />COMMENTS: / 4,7 . 2- Loe (II fc <br />o DESTRUCTION (choose type below) <br />II OVER-BORE <br />fl PRESSURE GROUT <br />WORK TO BE PERFORMED <br />J3KEW WELL BORING ( CPT, 9EOPROBE, HYDROPUNCH, HAND-AUGER 0:19J2R-) <br />i‘SOIL BORING # 41 <br />ArCVELL # 04 lAJ-- fv1L0--- <br />TYPE OF WELL <br />MONITORING <br />EXTRACTION <br />ci VAPOR <br />1:1 AIR SPARGE <br />.g'SoiL BORING <br />O OTHER. <br />INSTALLATION TYPE <br />OLLOW STEM <br />C AIR HAMMER/DRIVEN <br />jAMUD ROTARY <br />I] PUSH POINT <br />LI HAND AUGER <br />fl OTHER <br />CONSTRUCTION SPECIFICATIONS <br />DIA, OF BOREHOLE O .' MULTIPLE CASINGS? fi YES 300 WELL CASING DIA: <br />CASING THICKNESS .11-1+ (-10 TYPE OF CASING: ['STEEL QtVC El OTHER <br />DEPTH OF GROUT SEAL /6,..:710 3 TREMIE TYPE TO BE USED: 1FAUGERS 111-10SE <br />GROUT SEAL PUMPED; Yes fl No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />APPROX. BORING DEPTH °:110‘ )(BOLTED TRAFFIC BOX or fi STOVE PIPE <br />CONDUCTOR CASING PROPOSED? AA, ( If YES, list specifications here): <br />COMMENTS: (JO .+10 --"Ci ( -to r,44-6,_ ) <br />emw -s-ce =_ <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: "1 certify that in the performance of the work <br />for which this pen,* 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: 1 certify Mal 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 />..CAL,113145,14,NIV1ViktPET0R, r4VwpkKigGIIRS IN 'ADVANCEPCiRAWREQUiREDANgFiEttrONS. <br />Signed x Title/Company COL 71-1.4-ke-i-YI,A <br />Print Name Jcu.,t Alic-h-ter-Zovc-re_ Date -7 - -620 <br />DEPARTMENT USE ONLY <br />Apolication Accepted By Date Issued <br />Date Final Inspection By Date <br />Date <br />ACCOUNTING ONLY: <br />PE CODES FEE INFO AMOUNT REMITTED CHECK U RECD BY DATE INVOICE <br />1 <br />ERMIT I S CEtILtJ <br />30° I MU-) 81 lot 2_2-7 014/442 0339-5 <br /> Areacay, <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS I CONDITIONS: <br />1