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08/13/2002 15 46 2094SB3433 FIFTH FLOOR PAGE 01 <br /> ✓ Post-It' Fax Note 7671 Dare �{ (3 02 Qe9es► Z. <br /> To Sc f^ Frorn /en r <br /> WELL PERMIT APPLIA oi,,D-rl CctL4A 2-G �H <br /> Pnonca# Phone��c� <br /> SAN JOAQUIN COUNTY PUBLI Fax# �p S- C Fax <br /> ENVIRONMENTAL HEALTH D <br /> 304 E Weber, Third Floor, Stockton, LA-, <br /> (209) 468-3450 <br /> NON-REFUNDABLE pERrw%IT EXPIRES I YEAR FPOM DATE ISSUED <br /> ppl.cattan is hereby made to San iwquin County for a perrrut to constrva analor,n%all the work dti-scribed This apps cation IS nide n compliance wilt+ <br /> an Joaquin County De,-elopment T itle Chapter 9-1115 3 and the Sbndards of San Joaau+n County Pubtrc Hoatth Services Environmental Health Dw+tlon <br /> ASsossors <br /> 1ELL Locotion 6<�Iler ',AZross Stteet , City T x LP_2.a1M_ParceW <br /> RQPERTY Owner 1. ddress 1 V r �--Si� -City I(E'vPa'lrA �f zd6f?h0ne 9Y 9-7,�Z L/SS <br /> 57 Contractor JQo 4Lddress a looms C,ty LL zip -25`31 <br /> [ Lt rib . ..rt"F�P l Sf 6( C� Soruv�,�. Uc Ph"'e4 7a 7�5135 ASO <br /> onsultant!Sub Contractor �« r-✓' AdCreSs ?� 3 ay <br />,IS Coord.nales-X Y J Towtrshtp Range Simon__- — <br /> VORK TO BE PERFORMED <br /> W W I BORING(CPT GEOPROSE HYDROPUNCH HAND-AUGER OTHER") Q DESTRUCTION(Choose We tMIpw) <br /> SOIL BORING A Q OVER BORE <br /> r$WELL 9 M Lt- f t ' �`f t/-/J ' �p�_ iI PRESSURE GROUT <br /> Other V_ <br />'--MMENTS <br />- P OF WELL CONSTRUCTION TYPE CONSTRUCrtON SPEGtFICATIONS <br /> ORING Q HOLLOW STEM DIA OF SOASHOLE MULTIPLE CASINGS�y�YES Q NO wEtL CASING DIA <br /> f4 <br /> I FSC "A'TION Q AIR I�AMMERIDRrVEN CASIrtG THICKNESS TYPE OF CASING II STEEL Q PVC Q 0T14ER ^! 4Sv� <br />)VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL n j f TREmE,TYPE TO BE USED p AUGERS D1iOSE <br /> AIR SPARGE PUSH POINT GROUT SEAL PUMPED 'Yes p No (NOTE_ MAXIMUM FREE-FALL DEPTH IS 301 <br /> SOIL BORING O HANG AUGER APPROX BORING DEPTH 1<0(_(20j _ BOLTED TRAFFIC SOX or Q STOVE PIPE <br /> OTHER X �a�� "r tf 6" CONDUCTOR CASING PROPOSED? (If YES rist speaFcawns here) <br /> GOMMElITS` e t,,. rt t <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS! <br /> I hereby carbfy that I have prepared thLs appllcaaon and V+at the work w,u be done in accordance voth San J03qu+n County Ordingnces.State Law&and Rules <br /> and Reg utations of the San Joaquin County Homeowner or 4censed agents signature cerbfes the,following "l carory that in rhe performance of the work <br /> for wh,ch this permit is issued,f shall not employ persons subject fo WORXMAN S ComPEWSATION Laws of Cnhfornra.' Contracsal's lung or sub- <br /> contracting Signature t eR+feS the loltowsg 'I certify IhW or the performance of tho work rot which rh,s perms is rssu0<t. 1 sholl employ persons subject to <br /> WORKMAAr'S COMPENSAT70M I.aws OfCOOCtrn+a.' <br /> ? THE APPLICANT MUST CALL QB HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS <br /> Signed x c fr r <br /> Title , " a I/ is �'1c-�=' Date O 3 <br /> SEE SITE NI'AP IN UNIT IV WORK PLAN DATED <br /> I DEPARTME=NT USE ONLY <br /> Date <br /> Application Accepted 8y I.��.ca ��-+�+ issued D - Area <br /> Dale Final Inspection BY Date <br /> Grout Inspection By <br /> Destruction tnsooctlon By Date <br /> COMMENTS I CONDITIONS- <br /> F Ica <br /> ACCOUNTING ONLY AIDE <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKMCASH RECE)VED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE <br /> 3 ��( � lao � O <br />