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: 05/15/2000 08:21 209468 �.,_ FIFTH FLOOR PAGE 02 <br /> WELL PERMIT APPLICATION FORM UNIT IV M <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) JUN :j p <br /> 304 E. Weber,Third Floor, Stockton, CA-, 95202 20pU <br /> (20g)468-38449 FNVih�mvjEivl HEALTH <br /> NON-REFUNQABLE PERMIT EXPIRES YEAR FROM DATE ISSUED <br /> DER�IIT, VICES <br /> on <br /> Application is hereby made to San Joaquin Cve 9 11rt5sand th0 Standardsat ctofSart JoaVoinistallquin County Public Heath is Services,Envilication is ronmee in nts,Health Health Division. <br /> San Joaquin County Development Title,Chapt Assessors <br /> est Chum rwa� cross Street ��nCoIN S}• City 5 L Tip <br /> Tfix-M ParC2# =�0 <br /> WEL1-Location p 11 , Iia !nf� 5 �{'yam Zp�q Phone# <br /> PROPERTY Ownar RON Z IlV � Address_ <br /> S6D r\1yf!Ra _City <br /> C•57 Comradar IeIro�W sl; Le Address �_Wk <br /> 11 J1,� r• Ix. 3330 it., PrRDr,4r5`20Ciry�i -ion Lie# Phone# <br /> Consultan4 f Sub Contractor ST/AN Cv Vc!n t ArJdress�}..9. Sectivrt <br /> Ttnvnsnlp��Range----~ <br /> GIS Coordinates:X� 'Y-•-- , <br /> WORK TO BE PERFORMFAbelow) <br /> ` /' �DESTRUCTION(moose type <br /> TF NEW WELL I BORING(OPT,GEOPROBE,HYDROPUNCH,HAND-AUGER.OTHER') 0 OVER-BORE <br /> d OIL BORING# D PRESSURE GROUT <br /> •Other: <br /> COMMENTS: 'TWp <br /> rnauu a cw IQ,+C + G <br /> .TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS CASINrjS?y <br /> ONITORING �'FiOLLOW STEM DIA.OF 80REHOLE 1.'-° <br /> MULTIPLE OF CASING YES E NO L CHER'IA•� <br /> 0 EXTRACTION p AIR HAMMERIDRIVEN CASING THICKNESS <br /> Q VAPOR p MUD ROTARY DEPTH OF GROUT SEAL10."Da TREMIE TYPE 70 BE USED: Q AUGERS HOSE <br /> 0 AIR SPARGE PUSH POINT GROUT SEAL PUMPED: ,o,�es r➢Nv (NOTE�:nMAXIMUM FREE-FALL DEPTH 13 30') <br /> APPROX.BORING DEPTH 2j.1 0LTED TRAFFIC BOX of U STOVE PIPE <br /> 0 SOIL BORING q HAND AUGER a5 If YES,list specifications here): <br /> OTHER CONDUCTOR ca�sINC,PROPOSEDI_� <br /> ppe tER. ; ,i O n rt e�f� ( t Q�CI .•F a �o l�wk e <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT T PERMITS aws,ane Rules <br /> I hereby teNfy that I have prepared this application and that the work win be done In accoNance with San Joaq ` <br /> and Regulations of the San Joaquin County. Hamoewner ae licensed agents signature aertities the following:"I certify that In fhC perfomlanCe of the Work <br /> forwhich <br /> gt signature cerldas the following-hall t!Capttify Nre ren the Pe'�7^ance of ns subject to e tvork forwhich this permit r�Isssuued Of f T sshaul emA oY ns sub'ect laud .J. <br /> WDRKERS'GOMPENSAYION LawS ofCafrfomia." <br /> � 7i lelCompany <br /> Signed>< �6`"' �V V <br /> Date ) <br /> 3 <br /> Stu cNe rc <br /> j, r n <br /> Print Name <br /> ' <br /> Ell <br /> � ,� <br /> SSW <br /> DEPARTMENT USE ONLY <br /> I Data Issued reams <br /> Application Ac:mpled BY Final Inspection By n —Date <br /> ZoN�AJp Data <br /> Grout Inspection BY - Date <br /> Desttudian Inspection By <br /> COMMENTS f CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFOC <br /> . AMOUNT REMITTED CHECK# RED BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> U P <br /> �ll: <br />