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FTF lOC}R PAGE 02 <br /> WELL PERMIT APPLICATION FORINT <br /> IRE", <br /> SAN JOAQUJN COUNTY PUBLIC HEALTH SERVICES <br /> � <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) JUL 14 2000 <br /> 304 E.Weber,Third Floor, Stockton, CA., 95202 <br /> (209)468-344.9 ENVIRONMENT HEALTH <br /> NON-REFUNDABLE_PERMIT EXPIRF,S 1 YEAR FROM DATE ISSUED PERMIT/SERVICES <br /> Application Is hereby made to San Jouqufn County for n Permit to conatrvct andlor install tho wort:dnscribod. This application Is rnnde in compliance with i <br /> San Joaquin County Daveter7nrent Tilio,Chaptor 9-11 15.3 a nd the Standards of Son Joaquin County Public Health Servicas,Envlronmeritol Health Division. <br /> ASSCZua� _ C/ ! s <br /> WEt_LotatEoCity Parcet <br /> PROPERTY Owner ClTY._ D ( _`SJaP--c+ Address nYSN•�`1�or..�np. City , -r,�7ip 2o PhoneAt ar�GG <br /> C-STComractor tdo, J,)-eA Vo-d, ACdrasS�i}D R1dC!' Ro�� CitV? 11r'o! p9YS 7J Lleu 99.7 PAone�t7D7 37541.31l6 <br /> eon:vttantt5ubcontraetOrL/GL6 �rlJrre..KG4 �Address3�Lr/Uaf� t+..y�l. CityoPi�lroG/+df<YJc?f PhonatL 'srJ�-��73 <br /> GIS Coordinates:X .Y ,Township Range Section <br /> WO RK 70 BE PERFORMED <br /> OF-W WELL I BORING(CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER-) I}DESTRUCTION(choose type helow) <br /> g SOIL BORING 9 1]OVER-BORE <br /> a PRESSURE GROUT <br /> -other: <br /> COMKI;ENTS: <br /> i <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIpFICATIONS <br /> IPNOPJITORING VIOLLOW 5TCM DIA.Or 6OREHOLE 4 MULTIPLE CASINGS?Q YES 12 NO WELL CASING DLA: , <br /> 1]EXTRACTION I]AIR HAMMEWORIVEN CASING-1H1CKNESS-S&A. `(n TYPE OF CASING: n STEEL ZPVC LI OTHER: - <br /> p VAPOR 13 muO ROTARY DE=PTH OF GROUT SEAL u' -L a TREMIE TYPE To BE USED: I]AUGERS ,SiOSE <br /> (]AIR SPARGE Q PUSH POINT GROUT SEAL PUMPED: N'Ycs 9 No ()VOTE: MAXIMUM FREE-F'ALI-DEPTH IS 30') <br /> p SOIL BORING l]HAND AUGER APPROX.BORING DLPT'H„R 0 Af I- POLTED TRAFFIC BOX or p STOVE PIPE <br /> n OTHER: (]OTHER CONDUCTOR CASING PROPOSED? N O (If YCS,list gpaclAcations here): I <br /> COMMENTS, <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby Certify that i have vropared ttti,application and that the work wfll be dorso In accordance with San Jopgwn County Ordinances,Stuto Laws,ontl Rutc5 <br /> and Ro!3ulali0a.3 of the 3an Judyuin County. Hamcovmcr a iicenuort agcnra aignature cur tirlca tho followingr"1 cerrrfy that In the perfonnance of Ilic work <br /> fur wkfch this perrn'f is issued,t sn I not employ persons subject fe WO1fKERS'C0MPt:NSATlO1V Laws of C.10orrria," Conti odor's hiring or sub- <br /> Contracting sirJnat ertifins the ring:'f cnrtlfy that in the porfJnnanoo offhe work for which this permlf L;Issued.l shall employ parsons subjacf to <br /> 1NORKERS'Ct,O flplcL' SA'efOX f 0difurrva" <br /> i4! k' If44kp'3;tOR 4' W. _l�L�N,R5.44-AI3VA'NCEhFQIt iCLI'; QCilf{Ep�11�`rF;{�� IdtFB' <br /> SlJnad x TillolcompanyC a'�1_^ ✓]v I✓ .'f Lr'- I <br /> STRATUS ENVIRONMENTAL, INC. WELLS FARGO BANK,N.A. 1315 <br /> 4909 FIR AVE SEAL BEACH,CA 90740 <br /> SEAL BEACH,CA 90740 91.11911221 4 <br /> (562)799-7799 <br /> PAY TO THE ~r pct <br /> ORDER OF <br /> I )11 VL'P=• (. !0( ) -- -- -- - DOLLARS <br /> ..., .� _.. S"Iylpenes S <br /> - e 17cAMne <br /> aeu,b m CuH. <br /> 1 <br /> r, 1 <br /> �r f}7 f <br /> MEMO�Ii -- <br /> 11-0013LSIr■ I: L221011911:0911 5222 11• <br />