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N/02/2000 THU 12:42 FAX 916 777 4101 V W DRILLING INC <br />I <br />I;11003 <br />niRl31`1 : I3ETTLEP-PYRN INC. PHONE NO. : 916 671 1317 <br />Na.). 02 2000 11:22AM P.7, <br /> <br />WELL PERMIT APPLICATION FORM <br /> <br />UNIT IV <br /> <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-REFUNDAEILE 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 i 3 rnodc in compliance with <br />SRn Josouin County Development Title, ChaptiN• 9-1115.:1 and the Standards of San Joaquin County Public Hoolth Services. Environmental Health Division,. <br />WELL Location 41/v. pi <? 7 Z-.7 A/4"-it. ifrir Cross Street Ze3*-• "JA City S 7111'1/ Zip gs-,24)., PaYce <br />r) <br />7 """( <br />Assesso, <br />PROPERTY Owner Z 2/ .7".'55;t-'"."7"*"'", Address City ..r P1-1 Zip gf:Z:: 4'4 Pnone174' ?-7 rz-OP,'.;(7 <br />C-57 Contractor V*-4/ Adclress ci ty 177, •9:/../ Liott7Z Yelf ph onete7V•T 1710 -_,,21-/S- <br />Phonis#Y/e <br />Range Section <br />ZC <br />Consultant / Sub Contractor ..e"-.)-7z4.-Z ":"e'reW.Address 7-1sYgpe...1, 2), City LIc# SV".Xlie <br />fo 246 <br />Ms Coordinates: X , Y . Township <br />WORK TO BE PERFORMED <br />2 11/10 WELL PONG RI (OPT. GEOPROBE, HYoRopUNcH, HAND-AUGER, OTHER') <br />0 SOIL CORING # <br />,._1/VELL # a- 3 <br />DESTRUCTION (choose type below) <br />OVER-RORE <br />0 PRFSSURE GROUT <br />'Other. <br />COMMENTS: <br />rtp! OF WELL INSTALLATION TYPE <br />-(3-NITORING 70"-HoLLOW STEM <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN <br />()VAPOR UMUD ROTARY <br />13 AIR GRARGE 12 PUSH POINT <br />0 SOIL BORING fl HAND AUGER <br />OTHER; UOTHFR <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE e MULTIPLE CASINGS? a YES 0 WELL CASING DIA <br />CASING THICKNESS SF: 4-, si b TYPF OF CASING: 0 STEEL O'VC 0 OTHER; <br />DEPTH OF GROUT SEAL S:91' io 4 TREMIE TYPE TO BE USED: 0 AUGERS pHos <br />GROUT SEAL PumPEO: _0-Yes ,1:1 No (NOTE:i MAXIMUM FREE-FALL DEPTH IS 30') <br />APPROX. BORING DEPTH .r.r '`7'.OLTEID TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR cASIND PROPOSED? ( if YES, list specifications here): <br />COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br />I hereby certify that lhave prepared this application and that the work will be done in accortance with San Joaquin County Ordnances, State Laws, and Rules <br />and Regulatiuns of the San .102DIJin County. Homeowner or licensed agent's signature certifies the fallowing; I cerrIfy that in the performance of the work <br />for which this permit Is issued I shall not employ persons .lubject to WORKERS COMPENSATION Laws or californie." Contractor's hiring Or sub- <br />contracting signature certifies the following: '7 certify that in the performance of the work tor which (his purmit ia Issued, I shall employ persons subject to <br />MAKERS' COMPENSATION Lawe of California." <br />THE APP LI NT MUST CALL 48 WORKING HS IN ADVANCE OR INSPECTIONS. . . <br />Title ,lifm,Az,)e. Date <br />Signed <br />SEE SITE MAP IN UNIT IV WORK PLAN DATED: <br />DEPARTMENT USE ONLY <br />Date Issued <br />Date ‘.k0 t 0 Final Inspection By <br />Application Accepted Sty <br />Grout inspection By <br />Destruction Inspeotioll <br />COMMENTS I CONDITIONS: <br /> <br />Da1c <br /> <br />S o AID4 ACCOUNTING ONLY: <br />DATE <br /> PER <br /> CE RtOUF OICE <br />---6;;0 LICENSED CONTRACTp13,:MVST SIGN,LicE,Ng,.4;wpwg,Rs'.coMp,Nsio'ION riEcLARATION <br />cAqi, 7cc,n 12rcc, (3 <br />UNTT TV - 6/23/99 /sign bkpg/MI <br />Coird 40 -Cr-X-0-e( <br />e b rout_ diu 11( ,) <br />re-ek <br />[TX/RI NO (337ft 21003 <br />L-)-' /v.4 ni24. ret WO 0 T1,117 12,; <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REO'D BY