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11/14/2005 14 59 2094683433 EHD PAGE 02 <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EECIENED <br /> 304 E. Weber, Third Floor, Stockton, CA., 95Z 2 <br /> (209) 468-3449 NOV 1 0 200 <br /> NOIR-REFUNDABLE PERMIT EXPIRES i YEAR FROM 1)ATE ISSU F�Y'i SC�I� <br /> ppltyabon Is hereby made to San Joaquin County for a permit to construct and/or install the work described Th,s , M Wince with San <br /> 3aquin County Development Title,Chapter 9-1115 3 and the Standards of San Joaqutn County Public I tealth Servs Division <br /> rAssessors <br /> - oS��3 Z <br /> Cosstet 3ckr � � fSZe- Parcet# Gf <br />(ALL Location 9 <br /> ROPERTY Ov ner L►I2�, 4�i �Gf h �^r A res nye Zp PPhone#� Iy�TA ,e Bct- <br /> ',��-� _Z b -1 ss .,R <br /> �r S� -yam 68R <br /> LA <br />-57 Contractor`~7rr�� i7r,11�. t )G'is<dd Crh� ep �L�c# Phone, <br /> ��, Sly G/Z� .33D <br />.onsttltant Bub Contractor ��r'S �riy, ��Alddres5 5�c> l�oR��S Jj- City rG! r/ 1�� Phone# <br /> its Coardinatm X Y .Township Range Section <br /> WOR <br /> TO BE PERFQRME13 <br />(NI <br /> WELL/BORING(CPT,GEOPROSE,HYDROPUNCH,HAND,AUG .OTHER') �]DESTRUCTION(choose type below) <br />( Oil BORING# 4�,6 -n. Lw -- R OVER-BORE <br /> 05-1 1 # A4 Lv-j Z:ft W-I4f t �'✓�1hr-I'S_ Q PRESSURE GROUT <br /> other <br />;OMMENTS- <br /> YPE OF WELL INSTALLATION TYPE CONSTRICTION SPECIFICATIONS <br />(MONITORING AHOLLOW STEM DLA_OF BOREHOLE Io r' MULTIPLE CASINGS 0 YES []NO WELL CASING DIA <br /> [`TION [I AIR HAMMERIDRIVEN CASING THICKNESS.��KOa TYPE OF CASING fl STEELPVC d OTHER <br /> Q MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO DE USI• fl AUGERS QHOS>= <br /> AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED [I Yes Q No (NOTE' MAXIMUM FREE-FALL DEPTH IS 301) <br /> SOIL BORING [I HAND AUGER APPROX BORING DEPTH 7'9_4D fl BOLTED TRAFFIC BOX or IZ STOVE PIPE <br />[OTHER _[OTHER CONDUCTOR CASING PROPOSF-07 (if YES Irst spea5caisons here) <br />.oMMENTs : 'Y-L� t Co-.� - �rLl.•,,I 4,>ip <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> hereby Certify that i have prepared this application and that the work will t?e done in accordance with San Joaquin County Ordinances,State Laws and Mules <br /> and Regulabons of the San Joaquin County Homeowner or licensed agent's signature certifies the following 'Y eef fy that in the performance of the work <br /> or which this permit Is issued,/.shaft not employ persons subject to WORKERS'COMPENSATloN Laws of Catrfomia" Contractors hiring or sclb- <br />*ntracting signature cerhAes the following !cert'(y that fn the parhrmanca of the work for which this permit is issued,l shall employ persons sublecl to <br /> NORKERS'COMPENSATION Laws of Cal'(omia" <br /> ti Y'"FO'R4kA k;REQWREDjNSPECTIC?NS� <br /> �.��8•�1I�,RK��G,_�,��`�N�V�+GE, _ AL <br /> Signed x TitlelCompany +1 <br />'rint Name Date 7 <br /> aOEM— <br /> EI' TMr;NT USE ONLY ,�)0t/ <br /> J 1� <br /> itpplrcabon Accepted 6y a Date Issued r'`�Fl✓ r ��� Area <br /> 3rout Inspection[3y date <br /> Final lnspechon By Date <br />)estrucbon inspection By Date <br />'OMt+,IIENTS 1 CONDITIONS <br /> UNTINGONLY AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# R c°D BY DATE Pt=RMIT 1 SERVICE REQUEST# INVOICE <br /> 350 t S� .0 1 �i �1 a ' <br /> IJ18/ZOG4 <br />