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7-01 - 1999 2 . asF l.1 FRU I P . 2 - <br /> I� N <br /> WELL PERMIT APPLICATION FOa <br /> CLE yL <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICESJUL D 7 1999 <br /> ENVIRONMENTAL HEALTH DIVISION ( PHS. <br /> 304 E. Weber, Third Floor, Stockton , CA . , 95UI�IIVIEN f /� L HEALTH <br /> (209) 468-3449 PERMIT / SERVICES <br /> NON-REFUNDABLE PERMIT EXPIRES t YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described . This application is made in compliance with <br /> 1 San Joaquin County Development Title, Chapter g-1115,3 and the Standards of San Joaquin County Public Health Services. Environmental Health Division. <br /> Assessor's <br /> WELL Location749 E . Charter Way Cross StreetGrant St . city Stockton zip 95206 Parcel# <br /> PROPERTYOwner Darpetro, , Inc , Address3450E1Camino cityCeres zip95307Phone#537 - 0771 <br /> Frontier Drilling 673504 <br /> C-57 Contractor Addres3.3.3J,.] - McDonaldRDGit� tockto6i� 5206Lic# Phone#6_69 - 0211 <br /> Consultant / SubConteactor Ca & Geophysical Addres,P • O . Box578341 city Mo dest4i,* Phone#5 2 7 — 12 4 7 <br /> GIS Coordinates: X Y., Township Range_ Section <br /> WORK TO BE PERFORMED <br /> N NEW WELL I BORING ( CPT, GEOPR08E, HYDROPUNCH, HAND-AUGER, OTHER*) p DESTRUCTION (choose type below) <br /> Q SOIL BORING # a OVER-SORE <br /> "Other: pWELL # VW — Vapor Well a PRESSURE GROUT <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING )a HOLLOW STEM DIA. OF BOREHOLE 8 . 5 MULTIPLE CASINGS? a YES QINO WELL CASING DIA: 2 <br /> 0 EXTRACTION 8 AIR HAMMER/DRIVEN CASING THICKNESS P VC 40 TYPE OF CASING: a STEEL )n PVC n OTHER: <br /> ff VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 15 F t e TREMIE TYPE TO BE USED: Q AUGERS ]HOSE <br /> p AIR SPARGE p PUSH POINT GROUT SEAL PUMPED: a Yes ItNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 301 <br /> a SOIL BORING d HAND AUGER APPROX. BORING DEPTH fi O n 1 u s M BOLTED TRAFFIC BOX or p STOVE PIPE <br /> p OTHER:.0 OTHER CONDUCTOR CASING PROPOSED? ( if YES, list specifications here) :, <br /> COMMENTS: <br /> NOTE : OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby certify that I have Prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, State Laws, and Rules <br /> and Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: "1 certify that in the performance of the work <br /> for which this permit is issued, / shall not employ persons subject to WORKERS' COMPENSATION Laws of California. " Contractor's hiring or sub- <br /> contracting signature certifies the following: 7 certify that in the performance of the work for which this permit is isaued, I shall employ persons subject to <br /> WORKERS' COMPENSATION Laws of Ca/ifomia. " <br /> THE PPL CANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed x _ Title President Datc 7 / 2 / 99 <br /> SEE ITE MAP IN UNIT IV WORK PLAN DATED 8 / 21 / 98 <br /> DEPARTMENT USE ONLY <br /> Applicatipn Accepted By_cfa:fz� Date Issued 7 — e IV Area 07Sio I <br /> Grout Inspection By Date Final Inspection By . Date <br /> Destruction Inspection By Date <br /> COMMENTS / CONDITIONS: <br /> ACCOUNTING ONLY; AIDS FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED HECK#! SH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> 3 -5I gt? - g - jS� '3 Go �l8/g CJly797 <br /> C-57 LICENSED. CONM16CTOR MINTSTGN I CLNSE $&WORJi EXS' CE�11 PENSATION DEG�:ARA1" ON <br /> VNXT XV - 6/23/99 /sign bkpg/MI <br />