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I -LIIII I LUL_JI's <br />ORIGINAL" <br />WELL PERMIT APPLICATION FORM UNIT IV <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 Joaquin 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 9-1115,3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />Assessor's <br />WELL Location 2 3 (0 Sq 56"ilk- Fe- .00(4 Cross Street City 4/4;4r6itAk Zip f630 Parceitt ••2 Y? —0 7 0 -10 <br />PROPERTY Owner TOS. edevko Address 2-3(0s-9 .r. ic4-rt Cc ktity /2/v-(4/p.4,495:54 7 <br />- • ' <br />C-57 Contractor -(0e.51- tVuziraPtk-- Address 3Z33 FM2 ..r.-uk la-te 6 City Piikreiii- 95-7112- Lica! :109 Phone# 5/i. 435 -7z 76 <br />Consultant !Sub Contractor L.? L'.-.GoZ Address0,7 kzli)oic Elk City'144CJW (4,4w, Lic# Pnone# c'ou <br />GIS Coordinates: X ,V Township 3 5.),4V‘ Range 4I Section 2L( <br />WORK TO BE PERFORMED <br />OIEW WELL I BORING ( CPT. GraPDBE, HYDROPUNC"14 . HAND-AUGER, OTHER') <br />SOIL BORING # <br />SWELL # MLA,— 7 <br />*Other. <br />COMMENTS: <br />1 ' <br />TYPE OF WELL <br />XMONITORING <br />0 EXTRACTION <br />VAPOR <br />El AIR SPARGE <br />OSOIL BORING <br />0 OTHER. <br />INSTALLATION TYPE <br />„54-1OLLOW STEM <br />0 AIR HAMMER/DRIVEN <br />0 MUD ROTARY <br />*PUSH POINT <br />HAND AUGER <br />0 OTHER <br />CONSTRUCTION SPECIFICATIONS <br />DIA, OF BOREHOLE E3" MULTIPLE CASINGS? a YES *CIO WELL CASING DIA;21) <br />CASING THICKNESScCA-4- t-10 TYPE OF CASING: 0 STEEL XPVC I] OTHER: <br />DEPTH OF GROUT SEAL/(3 TREMIE TYPE TO BE USED: XAUGERS XHOSE <br />GROUT SEAL PUMPED; es 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />APPROX. BORING DEPTH W I VOOLTED TRAFFIC BOX or U STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( h' YES, list specifications here): <br /> <br />phone# Fig- 2443 <br />o DESTRUCTION (choose type below) <br />fl OVER-BORE <br />0 PRESSURE GROUT <br />COMMENTS: <br />VA -Ct( 41)Li <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <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 />contracting signature certifies the following:1 certify that In the performance of the work for which this permit is issued. I shall employ persons subject to <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 />for which this permit Is issued, I shall not employ persons Subject to WORKERS' COMPENSATION Laws of California." Contractor's hiring or sub- <br />WORKERS' COMPENSATION Laws of California," <br />;CAL44.MRPKON117)18144$0,07r0R..:'.0.100A,Nq,'RRAiN 'APVAlicePORH ALLE raoiREDAN'tptatOts. <br />Signed x___,94 Title/Company St101-2- 1-veAccvvt\--0:-, AAA ?r,:ye_eir AtAk.ii.oek <br />Print Name--.§..K c\OCAA.Ncirk.c..vi‘c Data <br />. • --".11p55ristr.--h, , ILL • ,i•-r , itttr.' 0,1,17;., , , -4 , Trjr. <br />SM. <br /> <br />'ar.'X',..1 ...)A'!.., '.7: - ..:.. <br />Application Accepted By Date Issued q. 14-00 Areal/SI' <br />DEPARTMENT USE ONLY <br />Grout Inspection By Date Final Inspection By <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# EAc# <br />\ PE CODES FEE INFO AMOUNT REMITTED CHECK N REC'D BY DATE ! • 'T INVOICE <br />35E) l A.AAA) .0! ' /0/23 I 6*.Z 7 siut 002311105 <br />/18/2000