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DATE REC'D RY PE CODE. FEE INFO <br />AlOrt <br />AMOUNT REMITTED CHECK* <br />FAO* <br />PERMIT (SERVICE ReCluST <br />ACCOUNTING ONLY: <br />L fin (A) CASA_ Ccani-60 3 <br />c-5,7ucf...Nszp.ONTRAcri;),1:-Llya)".'r sIGN CESL scwoR0 <br />UNIT IV - 6/?3199 ./sigrs bkpg/MI <br />INVOICE <br />ECLARATION <br />S oo Li gko z_ <br />11!0/2000 THU 12:41 FAX 916 777 4101 V W DRILLING INC Z002 <br />FROM : [3ETTLER—R'(12IN I NC. PHONE NO. : 916 571 1317 Nco). 02 200a 11:21RM P2 <br /> <br />WELL PERMIT APPLICATION FORM <br /> <br />UNIT IV <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (FFIS-EHD) <br />304 E Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />NON-REFUNDABLE PERMIT ExiacKES I YEAR FROM DATE ISSULD <br />Appiioetion is hereby made to San Joaquin County for a permit to construct and/or install trio work doccried. This application in made in compliance with <br />San Joaquin County Development Title, Chapter 9-1115.'3 and the Standards or 533 Joaquin County Public Health Services, Environmental Health Division. <br /><4 _ <br />zip City Parce <br />Assessor's,..„, <br />,7,4 .—)77t"E"e7 ..rj '5Z iff WELL Location Cross Street <br />PROPERTY Owner /11:41--..,•/--, Cee ,0 Address J r >1 764'0 CIty.Z74,6Lz--JA Zip9°P/1 Phoneu q/2-. 51.70.5r <br />C-57 Contractor 6' Address 40,- 620)e r i City ", 16700,9er-1V Lic#772-61P4tPhone#4 ; --77C7 <br />\A.1 e2,1C eve <br />COr15Ultant I Sub Ccntractori -!,Yor-, —4.'6- Address 7./eSGir 41•.— ririol;k•.• City C441-44P4 Lic# Phone* . 7' <br />.4•4 2,c <br />GIs coordinates: X • Y , Township Range Section <br />WORK TO BE PERFORMED <br />4/ --- ALEVV WELL! BORING ( CPT, GEOPROSE, HYDROPUNCH. HAND-AUGER OTHER1 / <br />. D SOIL BORING tit <br />-A:WELL # a —,2 E2- ei-,21- /.Z‘.., e, v_ 3 fx„,.._.:....,..„7.4. <br />'Other: . J ./ <br />13 DESTRUCTION (cheese type below) <br />a OVER-BORE <br />fl PRESSURE GROUT • <br />COMMENTS: <br />TYPE OF WELL <br />--A0NITORING <br />n EXTRACTION <br />grIAPOR <br />"AIR SPARGE <br />U SOIL BORING <br />OTHBR: <br />coNsTRucTION SPECIFICATIONS <br />DIA. OF BOREHOLE? MULTIPLE CASINGS? CI YEO WELL CASING DIAWZ <br />DEPTH OF GROUT SEAL,5i;" TREMIE TYPE TO BE USED: U AUGERS 4-10SE 71 <br />(_;AING THICKNESS Cc"' TYPE OF CASING; 1:1 STEEL 'Aq'VC a OTHER: <br />GROUT SEAL PUMPED. AYes 0 No (NOTE: MAXIMUM FREE-rALL DEPTH IS 30') <br />APPROX BORING DEPTH. TRAFFIC TRAFFIC BOX or U STOVE PIPE <br />( if list Rpeelfications here): CONDUCTOR CASING PRoPOSED 7 <br />INSTALLATION TYPE <br />,'HOLLOW STEM <br />I AIR HAMMER/DRIVEN <br />MUD ROTARY <br />O PUSH POINT <br />HAND AUGER <br />OTHER <br />COMMENTS! 2. 4,1•4- , 2 VZa/ 7 7c ..."5";aida <br />ev,0 •••4), <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br />I hereby certify thot I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, State LEW3, and Rules <br />and Recut:4111ns of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: "I certify that in the performance of the work <br />rye which this permit is issued. I shall not employ persons subject to WORKERS COMPENSATION Laws of California." Contractor's hiring or aUt7- <br />contracting signature certifies the Following: "I certify thai In thv pcdormance of the work for which this permit Is issued, (shall employ porDons suoject to <br />WORKERS' COMPENSATION Laws of California." <br />THE A 'LiCANT.MDST'CAIA..48 1NRKI DNG: H RS, IN ADVANCETO,RAP- REQUIRED INSPECTI2NS• <br />. „ <br /> Title .0: /7412x-r. /410.-0,e4 it Data 11X--A <br />Signed k <br />SEE SITE MAP IN UNIT IV WORK PLAN DATED: <br />DEPARTMENT USE ONLY <br />Date Issued <br />Date Final Inspection By <br />Date <br />O.C) Area <br />Date (0"" Application Accepted s L_ <br />Grout Inspection BY <br />Destructiun Inspection By <br /> <br />COMMENTS I CONDITIONS: •••••• <br />11/0 2/2000 T ,:11 rr. ba 7 21 00 2 <br />