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LO/03/2001 10 23 2094683433 FIFTH FLOOR PAGE 02 <br /> WELL PERMIT APPLICATION FORM <br /> UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION ("PHS-EHD") <br /> 304 E. Weber, Third Floor, Stockton, CA , 95242 <br /> (209) 468-3450 <br /> NON-REFu IDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ae in compliance <br /> ith <br /> Applrcanou nis Ca n�De�etopment Td emade to San o Chapter 9-11f 15 and the Standards10 cons1ruct nvf San.loagwn County Publics H&31th Services o Fn4ttonrnantal HeaRh n1ws n <br /> San Joao rY Assessor's <br /> 2t Cross Street City S� Zrp�-Parcel# <br /> WELL toc:idOn 4315 INT. rloa — 4--930t.Y14to Addre�� t' D . BO�I -1016 9 G�tY 1� z+P9(_,�_Priont� CrI) 6 <br /> PROPERTY owrer� LA tM - <br /> .rcQ� 6� -5so <br /> C-57 Contractoddre' � Co <br /> Consultant)Sufi GonIractor YV1V,,& Vs�dttri�"�� tldrt�ss T P <br /> r S <br /> city honei4 <br /> GIS Coord,natt:s x Y <br /> Township Range Section <br /> WORK TO BE PERFORMED <br /> DESTRUCTION (choose type below? <br /> NEW WELL J BORING(CPT GEOPROBE HYDROPUNCH HAND-AUGER OTHER'} (I OVER-BORE <br /> SOIL BORING s t C - ( Q PRESSURE GROUT <br /> 0 WELL 8 <br /> -Other <br /> *�rrORINIG <br /> F WELL CONSTRUCTION TYPE CONSTRUCTION$PEGIFICATIONS"VeLHOLLOW STEM DIAD OF BOREHOLE 2 MULTIPLE CASINGS?Q YES Q NO WELL CASING PIA <br /> a EXTRACTION U AIR mAmMERJDRIVEN C^SING THICKNESS <br /> A TYPE OF CASING Q STEEL- a PVC Q OTHER <br /> VAPOR []MUD ROTARY DEPTH OF GROUT SEAL!90�. .. TREIWE TYPE 70 BE t}SED Q AUGERS prIOSEw <br /> USH POINT GiZOUT SERI.PUMPED tgjes nn No (NOT'r= MAXIMUM FREE-FALL DEPTH IS 30'} <br /> Q AIR SPARGE O T Q BOLTED TRAFFIC BOX or a STOVE PIPE <br /> 0j-101L BORING a HAND ANGER APpROX BORITIG DSP7" �I V YES•Gsz speart+ans <br /> cahere) <br /> a OTHER CONDUCTOR CASING PROPOSED? <br /> COMMENTS <br /> NOTE-. OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS! <br /> I nereoy Gerufy that t have preoatbd this�p71��iron and that the worn will be done,n accordance"th San jo3qurn County Ordrnant:ea.Sta;e LcG aws,and <br /> nd work <br /> and Regulations of the San JoaQs <br /> wn County Homeowner or Insed age-as signature certrFe>the fol ! f that'n tha P <br /> for which this permit is issued,f shaft not einpfoypersons svbjett fo WDRKAiAN'S COryIpENSATION 101r taws <br /> O/Csfilom+a:" Ganiracto�s li+nng or Sub- <br /> oontract+nq signature cerbries the Tollowrng.'t cerbly 0WIn the Pedormarrce of ft work for whish MIS perrrnt h+Swed.I 1ht11!employ p9rsonS su6Ject fv <br /> vv0PKMAnrS COMPENSATION tawSr of Cel+fornrd <br /> THE APPt.1CANT MUST CALL 48 MRS IN ADVANCE FOR ALL REQUIRED INSPECTfONS <br /> &&nod+t <br /> Czlr'� Trtle � �� eel late 9-28—D E <br /> SEE SITE MAP I UNIT IV WORK PIAN DATED $ - o <br /> pA ENT SE ONLY <br /> Date Issued !! ea•_ <br /> AppGcat,on Accepted BY Dare, <br /> Grout Inspection By <br /> Dane Final Inspection By <br /> aestniafon cnsDedron By Date <br /> COMMENTS f CONDITIONS- <br /> FACS <br /> ACCOUNTING ONLY AID¢ <br /> PE CODES FEE INFO AMOUNT REMITTED CHECIt#J AS1i f2ECE ED 8Y DATE isERNilT15ERVICE itEQUEsr NUMBER INVOICE <br />