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P i <br /> RECEIVED MAR 0 7 2000 <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 , 95202 <br /> (209) 468-3449 <br /> NCN REFUNDAaLE PERP11T EXPIRES 1 YEAR FROM DATE ISSUED <br /> Appi cation is hereby made to Sart Joa--in Coun'y for a per-nit to coneuo,a'a/or ins,a,l the .vofK desc nz-a' Ti-,.s app;cat on is r;ace in conp4anre Nit' <br /> Sar Joaquin County Development T itte C'ap'er 9_+1 5 3 and ,he Stancaros or Sar Jc?gjir Coln.^j Pu: C-eaim Se^d�ca3 Erivi,o^nertai Haait^ <br /> r { �,ssassor s <br /> WELL Location JS.�C V t Coss Street tiJ Cityt k h 1 Z'o 52��°a•oe' <br /> PROPERTY Owner z p <br /> rr <br /> C-5T GontraCor T-12 �t R�rn AddressZ2` _F ,�L -CityDIY I LIQ '0S a-ane:tSl0 'Z32-27Z-, <br /> ZZ-1 <br /> t� 3-, �+ !Q ;ty �1R�` L ^cneT iro ��-J'IG� <br /> ConsultantJ/Ssb Corw'a,'o• •ct'w= r. 4 Add-aas:; <br /> - <br /> GIS Coordinates X Y Towns-io fZarg2 _ 5`cion <br /> a� <br /> WORK TO RE PERFORMED <br /> NEW WELL I BORING(CPT GSOPROBE HYDROPUNCH HAND.AUGcti, 0-1 H EAR-) Q DESTRUC71ON(Choose Type below) <br /> WSCIL 3CRI14G w Z Q OVER-BORE <br /> fl�iNJELL= S] PRESSURE GnOU- <br /> 'Other <br /> COMMENTS <br /> T�41T�ORING <br /> INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> p HOLLOW STEM DIA OF SOF_-TOLE Z MULTIPLE CASINGS?a YES II NO ','V-=LL CASING OIA <br /> C= =51"1 Sic=i P o C n oT,�Go <br /> {} F- TRACTIO l �n�ic r .�t',lc� �n1v�i. �rS J� iri .� 'ESS, <br /> Q VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USEC o AUGERS pHOSc- <br /> [j A1R SPARGE PUSM POINT GROAT SEAL PUMPED 13 Yes X No (NOTE. MAXIMUM FREE-PALL DEPTH IS 30' <br /> SOIL BORING Q NAND AUGER APPROX BORING DEoTH r jJ SOLTED TRAF51C. BOX or Ll STOVE PIPE <br /> 07HER (i OTHER CONDUCTOR CASING PROPOSED? t If YES fist 5peCIT.Catlo•+s nere) <br /> • <br /> COMMENTS llz�..�- 1 _ <br /> Q 4 F r U � � �'y ' �a LL <br /> . !�� <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby certify that I have prepared this appllration and ttsat the work will be done in accordance wrth San Joaquin County Ordinances, State Laws and Rut <br /> and Regulations++'the San Joaquin County I-Iomeowner or licensed agent s signature Certifies the:ogowing 1 certrfy fhat 1r7 the performance of the wor <br /> for which Itis permit is fssuEd, !steal!not employ persons subject to WORKERS'COM ENSATION Laws of California ' Contractors Faring or sub <br /> contracting signature certifies the following I certify that in the performance of the wcek for which this permit is issued 1 shah ernploy persons sub)ect to <br /> VVORKERS COMPENSATION Laws of Calffomle " <br /> CALL THE <br /> UNIT IV 1N PECTOR 48 WORKING FIRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed X <br /> c x+Li TltlelCompany -� fi' L2._-�•�4 �^ x+4 �-�I� <br /> r <br /> cr Date L <br /> -10 -Cc <br /> Pent - DATEE� tir- <br /> Name $EESE�If-MAPN U1T:IV �tttOORK-PLAN _ _ ups— _ - <br /> .e,a... , E_--- <br /> / DEPARTMENT USE ONLY <br /> Applicatton Accepted By l4AAA,5^"'^ Date Issued Area <br /> Grout Inspection By Date Rnal Inspe�ron By [late <br /> Destruction tnspection By Date <br /> 1t1+1MENTS l CONDITIONS <br /> ACCOUNTINCs ONLY AD$ I <br /> PE CODES FEE INFO ANtOUNT REMITTED CHECK# REC'D BY GATE PERMIT I SERVICE F EQUEST# INvac>= <br /> 3�'v ev102A 3 � co OD 110 ._ <br />