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08;-21 2094GB3433 FIFTH FLC OR PAGE 02 <br /> WELL PERMIT APPLICATION FORM uIT& <br /> SAN �JCMAClU,IN COUNTY PUBLIC HEALTH SERVICES�� <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHU) JUL 14 Z000 <br /> 304 E. Weber, Third Floor, Stockton, CA., 35202 <br /> (209) 468-34413 ENVIRONMENT HEALTH <br /> NDN-RFCI=UtyDA>XE PE;FZ[itJlT EXPIRES 9 YEAR FROM DATE ISSUED <br /> PERMIT/SERVICES <br /> Appiicatlon is hereby made to San Joattain County for a permit to construct andlar install the work dr~scrbed. This application Is made in compliance with <br /> San Joaquin County Daveloprmrnt Ti3e,Chapter 9A 115.s and the Standards of San Joaquin County Public Health Sarviccs,Environmental Health Division. <br /> !�]j Asses:wr's <br /> 11yELLLOCatlan� rl�FLtie _ Crass atreat�4lr� .1 _a City.57oe.C& _ _Zip ,S.TPZ- Parcel# <br /> PROPERTY Owner �11 O f 5711-L vt Address 3 r{,i Ili i�o✓.�Qo City �n 'To'1 +p 2Gtf Phone#? X13 6G <br /> C-57 Corrtraotvrr 11 oo��+r•IL pr11��ac�Addrees v o rJ tr Deva✓! Cit Ur a l.� ip9 _71 Ltde Fn4ne#7D 7 37*-%3,q0 <br /> Consultant I sub Contractor C's ff) ', �nr7r o�,ke.r�a Address,3/1-N&1,1 Cv 0t cit).f CarAck* Phena#9�rr S`3C :2If13 <br /> r1S Coordinates;X—,Y Township Range Section. <br /> WORK Ta 915 PERFORMED - <br /> OF=W WELL I BORING(GFT,GEOPROSE,I-tYDROPUNCH,HANG-AUGER,OTHER*) DESTRUCTION(choose type below) <br /> q SOfL BORING# p OVER-SORE <br /> I&WEELL# Mlt�- lYt /�1td`T dPRESSURP-GROUT <br /> ,other;— <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRYCTION SPECIFICATI NS <br /> PONITCIRING W1-IOLLOW STEM DIA,OF eOREHOLE�_MULTIPLE CASINW Q YE8 ONO WELL CASING CIA- <br /> [I EXTRACTION D AIR HAMMERIDRIVEN CASING T1-nCKNE$S _-)aj.s/b _TYPE OF CASING; D 5TEtK Jr VC LIOTHER;, <br /> Q VAPOR D MUD ROTARY DEPTH OF GROUT SEAL0-L�.. TREMIE;TYPE TO BE USED: "AUGERS ,NOSE <br /> 13 AIR SPARGE b PUSH POINT GROUT SEAL PUMPED; Wes 11 No (NOTE., MAXIMUM FREE-FALL DEPTH IS 301) <br /> 0 SOtL SOR1NG D HAND AUCER APPROX.BORING DEPTH 1(-'r JPOLTEP?TRAFFIC BOX or D STOVI:PIPE <br /> a OTHER;, �OTHER _ CONDUCTOR CASING PROPOSED? N 4, (if YES,list spnclllcations here); <br /> cOI1AMEN`I'S: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby«6etlfy that 1 have Prepared thio;appli=tico and that the work will be dorso In accordance with San Joaquin County Ordinances,5tute Laws,and Rules <br /> and regulations of the San Joaquin County. Homeowner or licene+ad agent's signature cortifles the following:"I Certify thatIn the perforrAsace ofthe work <br /> for which ibis permit is ' ed,f SJr 1 oaf empro <br /> foypens sullied is irYi?RKE'R'S'COMPENSATION Laws of CaflFomi8." Contractor's hiring or sub- <br /> cmtrocting D,ignat rt!Zw the ng-,-1 Cartffp that in the perrotmance of the work far which this permit is Issued,I shall employ persons sukjet�t fo <br /> WORKERS'C P� $A'r10 f califomia." T? <br /> w yi aN OR.'�$'d 4G.'.,� yy���,1 a wPmYV'.�4`.! ' ../,.��« f..�.. � ., .. �+�v4 yY���, <br /> � .. I+�'lctSr�hl�:AYJ!iFl1�7F r �'S^YiC'7 �. ^,rl'R�K <br /> Signed 7dtetCarnpanyi , r/?VI✓'t�cnwlr + '=�. oa'_ � Nell <br /> Print No ` c3 Date <br /> SEEM <br /> DEPARTMENT USE ONLY <br /> Application Accepted By _ - _ —DO#issued _ —Area <br /> Grout ltlspaction Cy pate - _ Final fnspoaiori By_ _ —_ _ Mate <br /> Destruction hr:spection BY Dote <br /> COMMENTa I GONDITIONS: <br /> ACCOUNTING ONLY; AID$ PAQft <br /> PE COOP-S FEE INFO AMOUNT REMITTl=CJ CHECK 3f REC'ID BY DATE jPERMITI SERVICE REQUEST# INVOICE <br /> 1/18/2000 <br />