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4. .Z-07-200 12:31 PM FROM_ MUIR/WZI/WOODBRIDGE 09 369 9358 P. 8 <br /> 04/08/D4 THU 18:07 FAX j# _ 1 002 <br /> WELL PERMIT APPLICATION (FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC EALTH ,SERVICES <br /> ENVIRONMENTAL HEALTH DIV SION (PHS-EHD) <br /> 304 E.Weber, Third Floor, Stool n, CA,, 95202 <br /> (209)468.3449 <br /> NOWREFUN DABLE PEWT EXPIRES I Y FROM DATE ISSP <br /> Application is Hereby made to San Jonquin County for a permit to oonstmet andlor install thi i work decoritled. T'hi%appleation is made in Compliants with <br /> San Joaquin county Development Title,Chapter 9"11 t 5.3 and the Standards of San JoaAui s Calmly Public Health Servlees..Envirommental Health amsion, <br /> Assessor'sD�3^ <br /> YVELLLocatlon 200 S. Chert, CrossStraid a$0-23 <br /> di Ave, ity Lodi, +CA zip9S24D PareetVF <br /> PROPERTYOwner Henry A. Hansen Address 652 E. Piste St. ClIy L0((i, CA zip 95240 Phone449- 5,311 <br /> r 4 13e Ue'S frl0%1"V� <br /> C-57Gonttactor Addre3s City J0 Lic# Phone# <br /> Consultartti$utbCorrrractor SteRtien G. Muir ,gdim� P 0 13OX t52 City oc4bridQikl CPR�ne# 209..369-9421 <br /> GIS Coor&nates:X Y. Township Rarge_ 70 <br /> - -WOF TO 9E PERFQRM1r2. <br /> NEW WELL/BORING(CPT,GEQPROSE,tiYOROPUNCH,HAND-AUGER,OTHER") 0 DESTRUCTION(chaasa type below) <br /> Q SOE.BORING# 0 OVER-BORE <br /> 0 WEi,L* _ 0 PRESSURE GROUT <br /> ^Other. <br /> COMMENTS: 6w�c fell, will L't dQ4'eP vU P' h- 'offer .44 <br /> Tyn DF WELL INSTALLATION goN9rRqqTioN S!,ecwICA7i0 <br /> )&MONITORING p HOLLOW STEM DIA.OF BOREHOLE M LTIPLI=G4,INGS?a YES ONO WELL CASING DIA: <br /> b EXTRACTION )]AIR HAtrIMERIDRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL D PVC (]OTHER, <br /> Il VAPOR 11 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: p AUGERS DHOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED; 0 Yes ]]No (NOTE:MAXIMUM FREE•PALL DEPTH IS 30') <br /> SOIL BORING 1]HAND)AIJGIE.R APPROX.SORING DEPTH D 90LTED TRAFFIC BOX or U STOVE PIPE <br /> n OTHER: n OTHER_ CONDUCTOR CASING PROPOS D? :if YES,lis,Spddf cations here):_ <br /> COMMENTS. <br /> NOTE. OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby candy t at I have prepared th W epplicatlan and that the wo*will be done In gown ante with Salt Jnaquie County Ordinances,State laws,and Rules <br /> and Rsgulati mn of the San Jaaquin County. Homeowner or livened agenra signeturo cer fies the Nliowing: '7 certify that In the P00farmenee of the work <br /> lbr whfeh Ms permit Is fsatmd,f s Miff notamplaYPerso"stWoct to WOR1CF_RS'CO 1PENSATIOrf Laws of calKomle." Contractor's hiring or sub- <br /> contracting eigneture certifies the fallowing:i cern that In the peftmranae of It"work fa which this pe,alk is issued,t shale employ parsons subject to <br /> WORKERS'COMPENSAT1AAr Caws of Callfbrr#A." <br /> Ci4L-L't'IiE;UNiT IY:,t%�fsEG'T'OR <br /> 4%1NOR19HG HRS.IN;-A.W Kdt:FOR ALL REQUIRED.INSPECTIONS' <br /> Signeda 4L Tit4woompany President RIGHT WAY, INC. (Property Nr <br /> Print Nemo <br /> James J. Vers.eput Data 4/5/00 <br /> _ <br /> DEPARTMENT USE ONLY <br /> AppliWlon <br /> le Y- <br /> Applicatlon Accepted ay Datie Issuert"___ __ Area <br /> Ceram Inspection By Data Fin I inspection e r —Date <br /> Deslhectlon inspection ay Date - <br /> COMMENTS l CONDITIONS. <br /> ACCOUNTING CSN!Y'. AID# FACA <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'b 6Y DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 2✓�J <br /> 1/18/2000 <br />