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GI" 5 a e <br />"te2za1 /4 711adc-e-r <br />23&., St--7 4 <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-END) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />NON-REFUNDABLE PERMIT EXPIR SiY DATE ISSUED <br />Application Is hereby made to San Joaauin County tor a permit to congtruet and/or install the work dtscriattd. This application is made in compliance with <br />San Joaquin County Development Title, Chapter S-1115.3 and tho Standards of San Joaquin County Public Health Services. Environmental Health Division, <br />WELL Louation 23 S9 5, $4 ros.s Street <br />WELL PERMIT APPLICATION FORM <br />A City P-‘4 ....24(..0..-k- zip nc„, prrcnesrtt. r 5 24 9 -070-23 <br />UNIT IV 0 Fr <br />fmcit <br />co-Resid 0,21 -56 <br />liwoRK. TO BE PERR)RNIED <br />arslEW WEL_ / BORING ( CPT. GEOSIZOBE, HYDROPUNCH, HAND-AUGER, OTFIEF) <br /> <br />artoiL 'BORING 0 <br />I] WELL <br />'Other <br />a DESTRUCTION (Choose typo below) <br />OVER-SORE <br />0 PRESSURE GROUT <br />COMMENTS: <br />TYPE OF WELL <br />rj MONITORING <br />1:1 EXTRACTION <br />yap() R <br />D AIR SPARGE <br />SOIL EORrNG <br />OTHER: <br />ro <br />INSTALLATION TYPE <br />0 HOLLOW STEM <br />0 AIR HAMMER/DRIVEN <br />o MUD ROTARY <br />OUSH POINT <br />HAND AUGUt <br />El OTHER <br />CONSTRUCTION SPECIFICATIONS <br />OF BOREHOLE 3 ° MULTIPLE CASINGS? 0 YES RINIO WELL CASING DiA. "— <br />CASING THTCKNESS TYPE OF CASING: ['STEEL 1:1 PVC ri OTHER: <br />DEPTH OF GROUT SEAL VS TREMIE TYPE TO BE USED: 4,8 AUGERS elOSE <br />GROUT SEAL PUMPED7 Xres I1Nn (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />APPROX. BORING 'DEPTH • BOLTED TRAFFIC BOX or 11 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? PO If YES, is: specifications here):—.— <br /> <br />C/C COMMENTS: (14 6. 674 / <br />Date <br />PE oiDDES <br />3fo <br />07/12/00 WED 10:33 FAX 1 916 861 0430 SECOR-SACRAMENTO <br /> <br />002 <br />04/20/2E00 08:23 2094602433 FIFTH FLUOR PAGE 03 <br />ORIGINAL icts' <br /> <br />PROPERTY Onrrier_CQQATY Oc SAL) JO/h/Zr-) Address S: CO3-AtiLee, ad. j.mge? City Zip Phone* <br />C-57 Contraanr IC.iiL'v:ml‘m"1 ddrOSS 171 Si`'-'-iic Pigkce- CityVf-Ile/ Spig.Azipre5-2,52; llo0 68 3g (Sr* meg_ 2-cl - 1'7 z - 3 s7 0 <br />Consultant / Sub Contractor2E-0. g- krIEAMATer- Address 370 ki.61mE )0.4 City RA ca4-13vAudpj,1 02- Prione4aN - ERA- 0400 <br />I,-"-• at too <br />GIS Coordinates" X , Y Township _ Range q CACI- Section 14 <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br />rierey cernfy that 1 nave prepared this appleabon and that the work will be done In accordance with San Joaquin County Ordlnanons, State Laws. and Ruins <br /> <br />and Regulations of the sari Joaquin County. Homeowner or licensed egfint'S sIgnalure certifies the -1 cerriry that in the performance of the work <br />for which this permit fs issued, !shall not ernp/oy persons sufVecf To WORKERS' COMPENSATION Laws of California." Contractor's hlrlog or sub- <br />contracting skinnture certlfle the following: "I certffy Mat In the porformance of the work for which this permit is issued. I shall emPlOY Persons seot <br />WORKERS' COMPENSATION Laws t7f-Celtfuu?ip ,. <br />CAL; Imp.N si,01...ort:40.W.P.R04, N ADVAN <br /> <br />TaleiCornParlY 1c0A Signed X <br />LLD kir <br />Final Inspection By <br />Print Name <br />APolication Accepted By <br />Grout Inspection By <br />Destruction inspection By <br />DEPARTMENT 1.16E ONLY <br />Date Is2ued <br />Date <br />Date <br />7—/it"— ° Area ObeCi <br />Data <br />Off <br />COMMENTS CONDITIONS: <br /> <br />cSice-tri-c <br /> <br /> 6175'7= "-• <br /> <br />111,;• 1/17)117011, <br /> <br />ACCOUNTING ONLY: AID11 <br /> <br />EE INFO <br />45E5 <br />AMOUNT REMITTED T INVOICE <br />11111MaRgaZil <br />/18 /2000 <br />/e/ 3 <br />CHECKS BY DATE