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11/28/2001 12 10 2094683433 <br /> FIFTH F7_0r3p FADE 03 <br /> LE: <br /> C�'�l[" WELL PERMIT APPLICATION FORM UNIT IV <br /> NOV 1 6 2001 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIR f LMENT HEALTH ENVIRONMENTAL HEALTH DIVISION ("PHS-EM1391 <br /> PERKT/SERort'�'ES 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3450 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSIJ9 <br /> Fpplication 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 /> an Joaquin Counly Development Title,Chapter 9.1115 3 and the Standards of San Joaquin County Public Health Services Environmental Health Dnrfsion <br /> WELL Location 24313 N Rt hW0 ,fig crossStr�eet 9-a� Kt d Gi Assessor`s <br /> � — r.�t5 5 M fr ^,zw PafGel�t 009- 160-19 <br /> PROPERTY Owner dress d� tX 1T3 S City Lo d i zip 95?`!4 Pisano 3lig}2 <br /> 91 <br /> C 6?Contractor I"l+`tC It t It D r 1111 X19 Address 106(S Nli 1(a tLo qy_Cdy 's-oVB Zrp�Licd �1 fi fhonefi 631– 3 5 0 3 <br /> ro-i-4- � 4x14 B ,O- CX 069 Et6 <br /> Consultant/Sub contractor R V I T t1 (. ddress h 6 p M hl� d<. city 5�5 6 2 32 3 Lia-51-56 Phone# 3 S►4-11's O <br /> GIS Coordinates X_ ` Y Township Range Section <br /> WORK TO BE PERFORMED <br /> 0 NEW WELL I CORING(CPT,GEOPROSE,HYOROPUNCH,HAND,AUGER,OTHER-) (l DESTRUCTION(choose type below) <br /> Q SOIL BORING n Q OVER-BORE <br /> Other IWELL 9 W—!J II PRESSURE GROUT <br /> COMMENTS f3%t, - S' 1r tJo)srtn �n Wall <br /> TYPE OF WELL ONSTRUCT ON TYPE CONSTRl1CTION SPECIFICATIONS <br /> #APOR <br /> OMTORING I HOLLOW STEM DIA.OF BOREHOLE –INCH MULTIPLE CASINGS?0 YES /NO WELL CASING)DIA 76-IN <br /> TRACTION n AIR HAMMER/DRIVEN CASING THICKAIESS Sur TYPE OF CASING b STEEL 5 PVC D OTHER <br /> ❑MUD ROTARY DFPTH OF GROUT SEAL 63–F1=E Y TREMIE TYPE TO BE USED I AUGERS pHOSE <br /> "AIR SPARGE 11 PUSH POINT GROUT SEAL PUMPED I Yes 0 No (NOTE:MAXIMUM FREE-FALL DEPTH IS 301) <br /> p S01 BORING 0 HAND AUGER APPROX BORING DEPTI 0`F 1:E T =BOLTED TRAFFIC BOX or p STOVE PIPE <br /> Q OTHER CONDUCTOR CASING PROPOSED? MID (if YES,lest specrficabons here) <br /> COMMENT5 <br /> t <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 en aocordOnce with San Joaquin County Ordinances State Laws,and Rules <br /> and Regulations of the Sao Joaquin County Homeowner or Ilcensed agents signature certifies the following_"l certify Mat in the performance of the work <br /> for which this permit is issued t shall net employ persons subject to WORX1114AN'S COMPENSATION Laws of California" Contractor's hinng or sub- <br /> mnlracting signature certiites the following 7 cerlefy shat in the perforinance of the work for which this permit is issued,I shall employ persons subject to <br /> tNpRKMAN'S COMPS SA I avis o(e.8/ir0r7rf8 <br /> E AP (, T MU � IN ADVANCE FOR AL RF UIRED INSPECTIO S. <br /> Signed x . Trtfe Dale Z d <br /> SEE SITE MAP IN UNIT I I ORK PLAN DATED aM s 4 S t 11 Z no <br /> DEPARTMENT USE ONLY , <br /> Application Accepted sy Date issued..�� �f1 f <br /> Groul Inspection 8y Date Fina(tnspectfon By Dale. <br /> Destruction Inspection By Dale <br /> COMMENTS 1 CONDITIONS <br /> F=ACfF <br /> CCOUNTING ONLY AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHEVQXASH RECEtVEo BY DATE PERMITISERVICE REQUEST NUMBER INVOICE <br /> J <br />