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05/15/2000 08:21 209468 FIFTH FLOOR PAGE 02 <br /> WELL PERMIT APPLICATION FORM <br /> SAN JOAQUJN COUNTY PUBLIC HEALTH SERVICES AUG <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) AUS 11 ?000 <br /> 304 E. Weber,Third Floor, Stockton, CA., 95202 ENVIRO <br /> -340 <br /> NDN-REFUNDABLE PERMg E%PGISES 1YEaR FROM DATE ISSUED PERMN SERV�E$TH <br /> Application is Hereby made to San Joaquin County for a permit to construct andtor install the work dasabad. This applicalinn Is maria in compliance with <br /> San Joaquin County Development Titla,Chapter 9-11175-8 and the S` lords of San Joaquin County Public Health Services,Environmental Health Division. <br /> d.�'asune w yam— sea <br /> WELL Location o roes slreetT'rJS� Cit Tiptl$3� -Q� areal# A'"D 1_1�-Dy <br /> n W, <br /> PROPERTY Owner •Add 81-Pt— <br /> C-57 <br /> s C-57 Cun1ractgr"erVeW6 1�(opa�ialt d1111252 F, 4)ood <br /> , ktv%kq Aw. _nCityl�w� p 9 n7Ludla$3" T�hene# -bL2'aR25 <br /> Consultant!Sub Contractor 5Tf41V5�rIViraA 1Ml.M1.`Atldress3DD(t nark Jl', C'rty�n. Lidf Phene#5�'6T6' <br /> GIS Coordinates:X_ .Y_,Township Range Section <br /> WORK TO BE PERFORMED <br /> )KNEW WELL I BORING(CP—r,GEOPROBE,HYDROpp,y{JTN HAND-AUGER.OTHER'T p DESTRUCTION(Choose type below) <br /> DIL BORING# S[h-1 1711 U/'I I]OVER-BORE <br /> WELL# Q PRESSURE GROUT <br /> "Other: 11--� 1- <br /> COMMENTS' VAI( 6 2hOpr TF itlli •IS eMt DA n6l- 4akk we# JLnb wa�(Jilt Qfgm}Init <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS h <br /> )IJONITORING a HOLLOW STEM DIA.Or BOREHOLE l Or• MULTIPLE CASINGS?BYES `<1NO WELL CASING DIA14 <br /> II EXTRACTION )41R HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 01, 17 OTHER; <br /> o VAPOR D MUD ROTARY DEPTH OF GROUT SEAL VnKet," TREMIE TYPE TO BE USED: 0 AUGERS JkHOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED; 'XYes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 31001L BORING a HAND AUGER APPROX.BORING DEPTH �.WBOLTED TRAFFIC BOX or N STOVE PIPE <br /> a OTHER; 0 OTHER CONDUCTOR WING PROPOSEDI Ho (If YES,IIs[speOlfl atians here): <br /> COMMENTS: ; UA hANIAwWiI ht"n'114161, <br /> 1f `mow Un .un2MI, hole Wol k o f IV well apmOk(A <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby certify that I have prepared thia applicaapn and that the work wll1 be done In accOrdance with San Joaquin County Ordinances,State Laws,and Rules <br /> and Reguiattone of tho San Jwquin County. Homeowner of licensed agent's signature oenifle the following:"I certify that In the performance of the war* <br /> for which this permit is lssued,i shall not employpersons suhNect to WORKERS'COMPENSATION Lam of California." Contractors hiring or sub- <br /> contmoting signature certifies the following: Campy that in the performance of the work for which this permit is Issued,I shall employ persons subject is <br /> WORHERS'COMPENSATION Laws of Cafi"I fwrda" <br /> Cs<%1lCdbJ'.,' s# :1RJ�RiiE 1OR:g8 g1�1$I,ItLC)iJC(41N'A4Y/AA/I/' / d�(LLj /y+y.4)I�R1EDFI/I) <br /> Signed x •� `✓fKt w ' TRIa/Company L `tel/4/V6 �n✓tionA/In <br /> Print Name SGD iRjAI Date <br /> DEPARTMENT USE ONLY 4\ <br /> Application Accepted B +p Oate Issued 5 lJ res <br /> Grout Inspection By D t eZ 0_f a� Final Inspeatien y Oata <br /> Destruction Inspection BY Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY; AIDff <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK 0 RECD BY DATE PERMIT t SERVICE REQUEST# INVOICE <br /> Z) -144, rg t5 6b A Z '13 � <br /> 1/18/2000 <br />