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2094683433 <br />FIFTH FLOOR <br />WELL PERMIT APPLICATION FORM <br />PAGE 03 <br />ORIGINAL <br />UNIT IV 7Cg <br />04/28/2000 @8:23 <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 96202 <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 />((ce4 2-(4 ‘- 0(00 - a -2-- <br />pAasrsesisor's <br />Phone# <br />C-57 Contractor We.si.- Pluz Aot- Address 3233 R Zip75742- Licit 55'1979? Phone#‘ia <br />Consultant 1 Sub Contractor" Address '3)il it: L,C,C 241 City LIcft (e..1,02.. Phone* <br />GIS Coordinates: X Y , Township fi) SE,%n Range Section 2'-1 <br />WELL Location <br />PROPERTY Owner (YIP <br />7 70 'Rpat / <br /> <br />d., Cross Street City Pait-uteg-.1: Zip ?5-34- 7 <br /> <br />TISS P-et, /544,3 <br />iu3; .4-rigs <br /> <br /> <br />2310 54LAITA. FeAI City Q_LittfiLic.-^ k 2 q53, <br />WORK TO BE PERFORMED <br />5NEW WELL BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER OTHER') <br />I] SOIL BORING # <br />11 WELL #,_JW‘J.-) - <br />'Other: <br />COMMENTS: I <br />0 DESTRUCTION (choose type below) <br />0 OVER-BORE <br />0 PRESSURE GROUT <br />TYPE OF WELL <br />-5.MONITORING <br />U EXTRACTION <br />fi VAPOR <br />fl AIR SPARGE <br />0 SOIL BORING <br />0 OTHER <br />INSTALLATION TYPE <br />It HOLLOW STEM —4> <br />AIR HAMMER/DRIVEN <br />MUD ROTARY <br />0 PUSH POINT <br />a HAND AUGER <br />fi OTHER <br />CONSTRUCTION SPECIFICATIONS 1--• <br />CIA, OF BOREHOLE 9" MULTIPLE CASINGS? 9 YES f,NO WELL CASING DIA: <br />CASING THICKNESS set-t • 40 TYPE OF CASING: 9 STEEL "'PVC fi OTHER <br />DEPTH OF GROUT SEAL r TREMIE TYPE TO BE USED: IS AUGERS 'HHOSE <br />GROUT SEAL PUMPED: ives fl No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />APPROX. BORING DEPTH BOLTED TRAFFIC BOX or El STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ./•Jtb ( if YES, list specifications here) <br />COMMENTS: <br /> <br />ett --,? li-frO +0 Li, 01 <br /> <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 thc Sao Joaquin County. Homeowner or licensed agent's signature certifies the following: "1 certify that in the performance of the work <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 />contracting signature certifies the following: "f certify that 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 />.CALL4;01,0NFTW1SI ,O M:j: . EdTOR , ?H.,ASHIN'ADVANcEtPOIRALOEQ,U.:IREDIN4FjEtTrfcihIS', , „ ,...,.. . . „.. . <br />Title/Company Pri2f--e-+ <br />Date 7- /Z%-z;1= <br />I tii r;;: <br /> <br />DEPARTMENT USE ONLY <br />APPlication Accepted By Date Issued -7--17 -°-& <br />Grout Inspection By Date Final Inspection By <br />Destruction Inspection By Date <br />COMMENTS CONDITIONS: <br />ACCOUNTING ONLY: 1 AIDA <br />7 <br />Signed x <br />Print Name ROCAA.ke.,rtbetiy_ <br />47.1.1ier <br />FAOtt_ <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # I REC'D Err <br />NW I toLz2 4 <br />1/1,g/2000