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neci The A 1v-12e-1_ DaI€_L/3 6 0 <br />Dale <br />SEE SITE MAP IN UNIT IV WORK PLAN DATED <br />DEPARTMENT USE ONLY <br />Dale Issued] <br />Final Inspection BY <br />Date <br />Applicabon Acetad <br />GroLl 1,504001 By <br />CostrJetion InspecNor By <br />COMMENTS I CONDITIONS <br />(Th Area <br />Cate <br />Re. <br />AID, ACCOUNTING ONLY <br />RECENED BY <br />TION <br />Oc 9oO <br />C.57 LICENSED CONTRACTORIIUST SIGN LICENSE &WORKERS' TION <br />UNIT IV - 6/23/99 tpq-, bkpg/MI <br />rih-E CODES FEE INFO AMOUNT REMITTED CHECK$1CASH <br />, <br />LA:# <br />DATE 141411418EiMMeE-ISE INVOICE <br />Dec 14 00 08:22a Chris Fisch (209)772-3571 <br />P .1 <br />Dic.',13. 11E )1:0EAY CNDOR EARTH TECHNOLnIES V.)::42iP. /3 <br />WELL PERMIT APPLICATION FORM UNIT IV - <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 4611-3449 <br />NON-REFUNDABLE PERKT EXPIRES I YEAR FROM DATE ISSUFD <br />AppIcains :s noreoy made ic San jOaq_nn CoJlty tor a permit to construct andtor Install the work desctrbed This application Is mode in complance won <br />San Joaquo County Development lids, Chapter 9-1115.3 end the Standards a San JOanum County Public Health Services Environmental Health Division <br />Assessor's <br />WELL Location 122N• cittini110iUs. St c foss soot rolra City CStrAllDriZiP Paroe•O__134 .- <br />PROPERTY Owner Caferki. SkOt. CILikddrae:Esuii (IDAdien .9de..., City LlfriBAXY1 Zai 9 Ott2erhon a* <br />Consultant f Sul) Conitactor ldress ti0e4 PN7flei <br />ic,tiVtZ <br />GIS Coordnates X Townshf Range p Sec-tien <br />WORK TO BE PERFQEMED <br />0 NEW WELL I BORING OPT, GS,BRRODE.HYDROPLINr74AND-AU T E 011 <br /> <br />KOIL BORINU* 45 If if 5 <br />wa.t# <br />'Men <br />G 'DESTRUCTION choose type beow; <br />0 OVER BORE <br />0 PRESSURE GROUT <br /> <br />COMMENTS <br /> <br />C,57 Con( tg r! tor. teas citAiltiSmq,A75? allicliiiVidb5 Ptioneii zog asthEaduirceno, e99,1her `6 • <br />TYPE OF VVLL INSTAL L ATION TYPE <br />fl MON,TORINC a HoLovv sick, <br />0 EXTRACTION G AW< HAMMER/DRIVEN <br />VAPOF, MUD ROTARY <br />0 AIR SPARSE 0 PUSH POINT <br />10575IL GORING C HAND AUGER <br />0 OTHER <br />CONSTRUCTIE_ <br />CIA OF BOREHOLE in. MULTIPLE CASINGS"; G yds 0 NO WELL CAS'NG DIA <br />CASING THICKNESS TYPE OF CASING 0 STEEL 0 PVC E OTHEft <br />DEPTH OF GROUT SEAL ISO TREMIE. TYPE TO BE USED. 0 AUGERS 0H9SE <br />DROUT SEAL PUMPED Yes No (NOTE: NIAXIMUM FREE-FALL DEPTH IS 30') <br />APPROX. BORING DEPTH 3,0 + • a BOLTED TRAFFIC BOX or STOVE PIPE <br />CONDUCTOR CASINO I*ROPOSED1 I if YES list specifcations here) <br />COMMENTS I.CLAgb An_z_PS,efssat_PSIL.R.Ser6ttLc PLA t ftt".")./-e- <br />t)Ivr C,cll ri:D1 1' • 1C CAA ' (T'i( <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br />I hereoy certify that have prepared this appkation and that the work will be done in aceordance with San Joaquin County Ordinanoty, State Laws. and Rules <br />and Regulations of the San Joaquin County Homeowner or kersed agent's sIgnature certifies the carroty that io the penformance of the work <br />for which this parritit is Issued. I shall not employ persons subject to WORKERS' COMPENSAT fON Laws of California." Contractor's t'irIn cr sub• <br />conlrocting slailature Certifies Inc following ;:artify that tn the performancs of 'ha work for which this pefrtrf is issued seattonlcioy persons suOieci to <br />WORKERS' COMPENSAT ,ON Laws of Caiifornds <br />THE APPLICANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS.