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10-18-1999 2702PM SM P. 2 <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E.Weber, Third Floor, Stockton, CA.,96202 <br /> (209)468-3449 <br /> NON:R CUNDABt F PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Appuoation is hereby trade to San Joaquin County tot a permit to construct and/or instau the work de3cnbed. Tris application is made in compllanca with <br /> San Joaquin County Development Title,Chapter 9-1115,3 and the SlYrgaros of San Joaquin County Public Haann SeMota,EnVI rohmental Health DNision. <br /> 7/Ac ,�,�,�/ %/t7G 1516 Assessor' <br /> WELL LodeHon �)epw Croea Stmt �! A� City zb Parcedr <br /> PROPERTY Owne/ra'/L16�Gv /dy)YS �A Atltlresa S1 ZiCfly li�Gc. zip 9�`�4honeu og-kI -Y&M 7u� <br /> 0J17 Contractor V i Q Y( d• irAld_dn/es !� _CKy _Licv Phone# �J <br /> u2✓ 'yT//ryw A(Wrassd7���/ALPid/ City �Idr r Phone# 5=313 �J <br /> Consultant/Sue Contractor ! <br /> / <br /> 0I$Coord-nates:X S'ee Well E�(,tE&1j ,Tawrshio P,S Rang* rSr- _Seaton_,_, ?T_ <br /> \YMRK M BE PERMRMED <br /> RrtJEW WELLI BORINO(CPT,OEOPROBE,HYDROPUNCH,HAND-AUOER,OTNIR-) p DESTRJC:"ON(shouse type below) <br /> a SOIL BORING O OVER-BORE <br /> DWELLy 0 PRESSURE GROUT <br /> 'Other: S°e_oML -0 /✓ Ayr �L y (� 4NJ <br /> WMMENT$; <br /> TYPE OF WELL INS TYPE CO i Clrl TI <br /> B MONITORING HOLLOW STEM GIA.OF BOREHOLE_& MULTIPLE CASINGS?U YESNNO WELL CASING DIA:,_,_,_ <br /> U EXTRACTION U AIR HAMMERIDRIVEN CASING THICKNESS CrA 9'0 TYPE OF CASING: 0 STEEL ` PVC 0 OTHER: <br /> VAPOR D MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS UHOSE <br /> U AIR SPARGE D PUSH POINT GROUT SEAL PUMPED: 0 Yas'10 (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> U SOIL BORING D HAND AUGER APPROX.BORING DEPTH, 130 / QLyEO TRAFFIC BOX or U STOVE PIPE <br /> D OTHER:—D <br /> ,r�D OTHERg. ,l CONDUCTOR CASING PROrrPPQSED?_,b[Q,__(if YES,list specifkatbng ham)!— <br /> COMMENTS: <br /> am): <br /> COMMENTS:47Jr 131 i r{.IL7'"S/ , 41 P✓ <br /> ,a �Hc�n-/lex .4ry �c/Pi _ <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> 1 hereby certify that 1 have prepared th14 app nation and that the work will be done In accordance with San Joaquin County Ordinan[eS,State Laws,and Rules <br /> and Regulations of the San Joaquin County. Homeowner or licensed agent's Signature certifies the following: "I certify th4t In the peBorveance oflha work <br /> for which this permit is issued,I shall not amploypersons suD/ecr to WORKERS'COMPENSATION Laws of Crriifomla." Contractor's hiring or suo- <br /> oontmoting sigraWro twtifea the following: "1 mr*thef in the Aerfwmanae of the work forwhiCh this permit is issued,I ohail employ Parsons suryact to <br /> wOgKERS'COXf NSAnOAr Lawa gf 'Iwrde."r <br /> E PPLIC T TGA ,. WORRING'HRS IN.'ADVANCE;'F, � ALL REQUIRED INSR C/7//7�ONS. <br /> Signed x .... YNIe S 64 r✓, C to <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED'. <br /> DEPARTMENT USE ONLY <br /> Application ACCAptod By Date Itiuett,.-,,, Area <br /> Grout Inllpectlon By Data Final Inspection By Oat <br /> Destruction Inspection Ey _ _ Dat <br /> COMMENTS)CONDITIONS; <br /> ACCOUNTING ONLY: AID# _ <br /> PE CODEg FEE INFO AMOUNT REMITTED DHECK s REG'D BY DATE PERMIT I SERVICE REQUEST 0 INVOICE <br /> 7,57 UCENSETY CONTRACTOR MUST SIGN LICENSE;&WCiW-O'COMPENSATION DECLkRATION <br /> UNIT IV-6/23/99 ANgh bkpg/MI <br /> Ii/E »' VE89660Z IV,�OILVN83LN1 NVIQVA! Nv60 8 t 0 Zi-6 V� "arras 8iEZZ9B9i6 A9 LN3S <br />