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Application Accepted By
<br />Grout Inspection By
<br />2astructiun Inspection By
<br />coMMENTS 1 CONDITIONS:
<br />FROM : GETTLER-RYAN INC.
<br />f17'02/2000 THU 12:41 FAX 916 777 4101 V W DRILLING INC
<br />PHONE NO. : 91E, 571 1317 No.). 02 2am .1 : 2.1.PH P2
<br />(94? 002
<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 EXI0 Nes 1 YEAR FROM DATE ISSUED
<br />Application is hereby made to San Joaquin County for a permit to construct and/or install tnc work doecribed. This application is mode in compliance with
<br />Sari Joaquin County Development Title, Chocter 9-1115.S and the Standards of Sari Joaquin County Public Health Scrv ices, Environmental Health Omsion. Assessor's
<br />WELL Location '5'17 FT- .".47.-..: /41/A0V7Z.. --C7r Cross street .1.4"4-r1-44'4 City .--St—:T'4.71 Zip 9:r. ''Z- Parcel/1, A.r C.)
<br />PROPERTY Owner Z4fle.,Z, Cee,i0 Address ,47 A Jr)z 7610" C) city ,ZrA..‘67--,r zipqoPI1 ph,„,, q/(.. "Ai .7e)Ar
<br />C-57 Contractor \ti i- 4'/ 13 A' Address a. e.20)4. .r. I C.,itY0' 47A/ if91-rIT/ Lic#7724144-Phone# 77V 2-fr/f
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<br />Conaultanti Sub Contractor-rre.c4 -oar.th," Z.-"C-- Address2 6),PL. City C.0.4 Licii 5.:1-772 Phone# 7117' ..,..V.........,
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<br />Gis coordi
<br />Township
<br />nates: X Y
<br />Range___--- Section ,
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<br />WORK TO BE PERFORMED
<br />— 41EvV WELL! BORING ( CPT, GEOPROBE, HYDRoPuNcH. HAND-AUGER OTHER") / a SOIL BORING it . oal_ # a -..z e• 6. --,z_f- tA ./.. 7 6, V- ,Y .100% -S.'4.7•G -
<br />./
<br />O DESTRUCTION (choose lype Lie.low)
<br />n OVER-BORE
<br />fl PRESSURE GROUT
<br />
<br />'Other:
<br />
<br />'710NITORING ,et:r HOLLOW STEM DIA. OF BOREHOLE? .0 A "MULTIPLE CASINGS? 0 YES-740 WELL CASING COMMENTS.
<br />
<br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATioN
<br />
<br />0 EXTRAC.TION a AIR HAMMER/DRIVEN CASiNG THICKNESS CC-Iv 45/ TYPE or CASING: 11 STEEL 'A)45 VC a OTHER:
<br />gClAPOR la MUD ROTARY DEPTH OP GROUT SEAL-5;r A=?cl.')
<br /> TREMIE TYPE TO DE USED: U AUGERS 410SE ...,,
<br />...1,dAIR
<br />
<br />
<br />SPARE 0 PUSH POINT GROUT SEAL PUMPED. AYes 0 No (NOTE: MAXIMUM FREC-riALL DEPTH IS 30')
<br />
<br />[(SOIL BORING u HAND AUGER APPROX. BORING DEPTH -51-1, 6._. t_L,_.'ale-BOLTED TRAFFIC BOX or U STOVE PIPE
<br />a OTHER:— a OTHER CONDUCTOR CASING PROPOSEW (if YES. list specifIcztions here): 7b
<br />COMMENTS: 2, Al A.1,4- ,/Z 0 L.)--i:)r7d 2 17"ts./ 7—.. z C 7-1 „4P.ida 4i
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<br />/As ‘4„/"0 (...7,e) .47..9'.. ,-...kA
<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 an Joaquin County Ordinances, State Laws, and Rule.s
<br />and Reoulatinns of the San Joaquin County. Homeowner or licensed agent's signature certifies the following:
<br />"I cAglify that in the performance of the week
<br />!yr which this permit is issued. I shall not employ persons subject to VI/ORKEIRS COMPENSATION Laws of California."
<br />Contractor's hiring or Dub-
<br />contracting signature certifies the following: 'I certify thai In the peiformance of the work for which rnis permit is issued, I shall employ porgons suojec: la
<br />THE A ANT.'MUL...TCA141..'481/VORKING:HRS, IN ADVATNICE-!rO,R,Ap., )q,.ILIIRED INSPECTIONS.
<br />. „ . . , . , . „
<br />WORKERS' COMPENSATION Laws or California."
<br />..c... Title ...50-5.-• 77`;'12"t-7? 0.-0.*4 az 0,02,
<br />Signed it
<br />
<br />SEE SITE MAP IN UNIT IV WORK PLAN DATED:
<br />DEPARTMENT USE ONLY
<br />Date Issued I i Area ---
<br />Date ----Final Inspection By Date
<br />Date
<br />ACCOUNTING ONLY. AlDit FAG* --
<br />PE COOLS FEE INFO AMOUNT REMITTED CHECK*
<br />EC7 \l
<br />DATE PERMIT I SERVICE RE•citiST # INVOICE
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<br />11/02/2000 THU 12:11 r TX/RI NO 6:1781 Zonz
<br />S 0 0 2-(-1 °1/4 6 -2---
<br />UNIT IV
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