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' 11/28/2001 12 10 2094683433 FIFTH FLOOR PAGE 02 <br /> WELL PERMIT APPLICATION FORM UNIT !V <br /> Nov x 6 20D1 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION ("PHS—EHD") <br /> EN'VRC N10EN T hEAi.i H 304 E. Weber, Third Flow, Stockton, CA., 95202 <br /> PE41VHT/,;W'1`jES (209) 468-3450 <br />' NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Applicatrvn is,,,rosy made to San Jaaqutn County fora Demi,,to construct andlor mslatl the work descnbed This app,catlon rs made rn conphance with <br />' San Joaquin County Development Title Chapter 9-1115 3 and the Standards of Son Joaquin County Public Health Services Environmental Health Division <br /> fi 5 t'0 G h 1'o k 9 5 0 Assessors <br /> WELL Location 1810 E. 4 YEI'YC AY$, CrossStreel a ti•t+rt tarty Zrp Z '� Pacel# - <br /> PROPERTY Owner Soh Zroqpti4 COUNty Address 1372 E. Scoffs Avg. City St0r-tto IiI, Zip !205 Phone# 46 P-091-1 S' <br /> �t n ?41 <br /> i <br /> C 57 Contractor Mttelt# I iM Address 1061% Mil 110 Wa Crfyrorg0V4. Zip95610 Licni„ hon 6;1' 8 <br /> Toff ftiama P-01 Rox 869 LtiG i916� <br /> Consultant I Sub Contractor ro Address I aro Glt t1 Mw_�et_,I�City 9 5 6 Lrcfi:�_Phone# 35 4 -3 5 0 <br />' GIS Coordinates X Y ,Township Mange Section <br />' WORK TO BE PERFORMED <br /> NEW WELL I BORING(CPT,GEOPROBE HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> 0 SOIL BORING# I]OVER-BORE <br /> 8 WELLt! MW-3 1)PRESSURE GROUT <br />' 'Other <br /> COMMENTS OvIt Ort-Slt� Mob%jtotelkj WtIl <br /> TYPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING /HOLLOW STEM DLA OF BOREHOLE -INC H MULTIPLE CASINGS?U YES t NO WELL CASING DIA �~tN <br />' XTRACTION a AIR HAMMEWDRIVEN CASING THICKNESS-SC 0 TYPE OF CASING a STEEL Ill PVC Q OTHER <br /> APOR [�MUD ROTARY DEPTH OF GROUT SEAL,31'F 0 E T TREMIE TYPE TO$E USED NALIGEIRS QrtOSE <br /> p AIR SPARGE Q PUSH POINT GROUT SEAL PUMPED g Yes ONO (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />' 0 SOIL BORING 0 HAND AUGER APPROX BORING DEPTH SS-F9 I-T II BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> a OTHER CONDUCTOR CASING PROPOSED? 140 (if YES,Inst specifications here) <br />' COMMENTS <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS! <br /> I hereby Certify that I have prepared this application 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 licensed agent's signature certifies the fotlovnng "1 celft that on the performance of the work <br /> for whit,this permit is issued,1 shah not employ persons subject to WORKMAN'S COMPENSA77ON Laws of Calrfornla" Contractor's hiring or sub- <br /> contracting signature ceftifiies the follovrurg 'I Cerfrry that rn the perforrrianee of the work for which this permit is issaed. I sha11 employ persons Sub1ect to <br />' WORKMAN'S COMPENSATION Laws of C8lAoririr <br /> HE PLIC 8 RS IN ADVANCE FOR AL REQUIRED INSPECTIO S. <br /> 01 <br /> Signed x <br /> Title � i Date f f 2 <br /> 1 SEE SITE MAP IN UNI IV WORK PLAN. DATED 7k1y I6 zObl <br /> DEPARTMENT USE ONLY <br />' <br /> Dale Issued <br /> Application Accepted By _ Inspection By Dater,..., <br /> Grout Inspection By Date Final <br /> Destruction Inspection By Date <br />' COMMENTS r CONDITIONS <br /> FAC# <br />' CCOUNTING ONLY AIDN <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#ICASH RECEIVED BY DATE PERMITISERVICEf F-UEST NLJtiRBER INVOICE <br /> A< ll�Z al d0 <br /> uNIT IV-6/1/99 /sign bkpg/MI <br />