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NOV-03-1999 17:30 C`TRIA INC. -1707 935 6649 P.01i02 <br /> WEL'hPoPERMIT APPLICATION F(7-nM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ( ' <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 E. Weber, Third Floor, Stockton, CA.,A., 95202 55202 <br /> (209) 468-3449 <br /> NON-RBFUNDABLE PERMIT EXPIRES t YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a Pemvt to construct and/or install In=work described This application IS made in Compliance dh <br /> San Jcapeve <br /> uin County Development T1Ue,Chapter 91115.3 and the Standards of San Joaquin County Public Health Senlcea.Environmental Heli ni awitDivision. <br /> WELL Location_ 2!194 Ff•e + S/ a Assessors <br /> Cross Street F�(J,rr+ city S+ock�oh Zip parcow <br /> PROPERTY Owner Win.1 /An •p 3s fL Address 3v,Fe Sa4Y one lilaf( -dy {rev.-, n zd 7700.E phone% <br /> C•57 Contractor i.i '/n11.:ll-x Addressgta Flel.iR ..l Ciry,M�.{;_..s Zip9T.Si's LiCl4aj/� PhOneR flS st; Snne <br /> Consultant/Sub Cantyctor L,A,wt��.�ti-`-cl— _Addre5s270 �ir4:N5 CT City Mm4 Lint phpnerR 7vj q;y�ry� <br /> GIS Coordinates X , 7 ,Township Range Section <br /> WORK TO BE PERFORMED <br /> it NEW WELL/BORING(CPT,GEOPROBE. HYDROPUNCH,HAND-AUGER,OTHER') 0 DESTRUCTION(choose type below) <br /> I(SOILSORINGt S9-4 SA•S [A• - OOVER•BORE <br /> A WELL t-S-4 0 PRESSURE GROUT <br /> PE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ItWONITORING %HOLLOW STEM DIA.OF BOREHOLE M MULTIPLE CASINGSo p YES V'NO WELL CASING DA 2" <br /> 0 EXTRACTION D AIR HAMMER/DRNEN CASING THICKNESS TYPE OF CASING: OSTEEL If PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL-s- t/3 Pk$ TREMIE TYPE TO BE USED. C AUGERS fiOSE <br /> 0 AIR SPARGE p PUSH POINT GROUT SEAL PUMPED: ,XYes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOtL BORING 0 RAND AUGER APPROX BORING DEPTHL(6 j _,!T,5 fjs J(SOLTLD TRAFFIC BOX Or p STOVE PIPE <br /> 0 OTHER._0 OTHER CONDUCTOR CASING PROPOSEU7 6 O (if YES,list specifications here) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby Canty that I have prepared this appllcadon and that the work will be done In accordance with San Joaquin County Ordinances,State Laws.and Rules <br /> and Regulations of the San Joaquin County. Homeowner or icensed agera's signature certifies the following: -7 ca"ify that in Me performance of fhe work <br /> for which this permit is Issued,/shall not employ persons subject to WORKERS'COMPENSATION Laws of Callbmla." Con"clor's hiring or sub- <br /> contnchnB signature certifies the fallowing:'f certiy,that in the perto/mancr of the work for which this permit u issued, l shall employ persons Subject to <br /> WORKERS'COAIPENSAT70N Laws of California.' <br /> 1EAPP CMUST.CALL 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed <br /> Ttle�lacf F,_•a it- Dala { <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED- <br /> LJ <br /> ATED- <br /> DEPARTMENT USE ONLYp- <br /> Application Accepted By — Date Issued- <br /> Gmut Inspection By Date Final Inspection BY Date <br /> Oestruc5on Inspection By Dale <br /> COMMENTS l CONDITIONS: <br /> ACCOUNTING ONLY: Afoot <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKS RECD BY DATE PERMIT/SERVICE REQUEST t INVOICE <br /> 3501 PS (r o5 <br /> C•57IlCEYSED CONTRACTOR MUST- IONS UCENSEGQIvIpEN$AI[ON DECLARATION <br /> ;&W - _ <br /> r <br /> tlh7lT LV-6123/99 lsign bkp9/M2 � � - - - <br />