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11/02/2000 THU 12:42 FAX 916* 4101 17 W DRILLING INC � [a 003 <br /> -Rum GETTLGR-RYRN�I ( E C 0 P PHONE 117. : 9.c 631 1:x17 Nov. 02 2G_100 11:22RI•I F'3 <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 /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DAYS ISSUED <br /> n is made In comPllance with <br /> Application it.hereby made to San Joaquin County fora permit to construct and/or Insall the wurx described, This applicatio <br /> San Joaquin county Development Title,Chapter 9-1115.3 and the Standards of Sen Joaquin County Public Honmh Services,Environmental ssassar Health Division. <br /> ,/ <J,r oz Parcels �7"%+�� <br /> WE LL 1,nnation Yie/N.'y 4�; �""Z'f Cross SVeet L-dt'F NIA City ''k' Zip�� <br /> �,yc+e�ooress�G� r City <br /> PROPERTYOwncr // -•`r n� <br /> p <br /> -1 <br /> C57 contractor Vi^L✓ //R�ti.ib Adoress /'/'� GS� City. <br /> '� � e�G'd�_' City G[a•r�+�+� LIudF Tri-'+# Phone#9 <br /> qq Y0dZ ddress <br /> Consultantl Sub Contragor C2�T7lr.Y aL<sd <br /> Range Section <br /> GIS coordinates:X y .Township ' <br /> WORK TO bE PERFORMED <br /> 17DESTRUC710N(choose type below) <br /> -, JEW WELL/BORING(CPP.GEOPROBE.HYOROPUNCH,HAND-AUGER.OTHER'f p OVER-BORE <br /> �` U SOIL CORING# 0 PRFRSURE GROUT <br /> WELL# 61-eY u�z 7 .. <br /> 'Other. ---"'— <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECI FICATI MIJLTIPLE CA,iINGs? YES /yc WELL CASING DIA Z <br /> ONITORING LLOW STEM DIA.OF BOREHOLE /' <br /> EYTRACTION HAIR HAMMER/DRIVEN CASING THICKNESS -�c' 90 TYPE OF CASING: 0 STEELpVG {]OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL Sy tr JOL TREMIE TYPE TO BE USED: H AUGERS 0HCSE <br /> p AIF SPPRGE PUSH POwY GROUT SEAL PUMPED'.Wes LO (NOTE: MAXIMUMOTRAAFFIICE-:E-FALL DEPTIri IS C BOX or U STOVE p PE 0') <br /> 0 SOIL BORING H HAND AUGER APPROX.BORING DEPTHI <br /> O OTHER-.—U OTHER CONDUCTOR CASING PROPOSED? (it YES,list spa <br /> clflCetiOns hare): <br /> COMMENTS: ` <br /> NOTE' OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby coRIW the[I have prepared lois appiiwtion and than the work will be done in acwroancc won Sen Jeaquln County Ordinances,State Laws,and Rwork <br /> ules <br /> and Reg r s•ub- <br /> ulatiuns of the San Joaquin COvunt . Homeowner or licensed agent's slgrature certifies the WOWing: "f certify that in the performance of the Jb- <br /> nature certifies the fallowing: 'I Certiy that in the padormance of the twrk for which this perthft fs issued,I shall employ persons subject to <br /> for which this permit Is Issued,1 shall not employpersons subfad to WORKERS'COMPENSAnON Laws of Crlifornfa." Contractor's hiring o <br /> contracting W9 <br /> WORKERS'COMPENSATION Laws of CRIJIUMie." <br /> THE APPLI NT I91U57 CALL 48 WORKING H9$IN ADVANCE_FbR ACL„^REOUIREp.INSPECTIO . <br /> / ^,K,.�Y/'/yncJG Data /� Z '00 <br /> •— <br /> Signed z i. <br /> 6 Tt,e J `- <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED: <br /> -iv V 1 DEPARTMENT USE ONLY J? Cc> Area,_ <br /> t� fj d <br /> Application Accepted By Date Iss <br /> Date�_ 1� Final In pection By Dare�— <br /> Grout lnSP"A'on By - <br /> Dale <br /> Destruction Inspeelion By <br /> COMMC-NTS I CONDITIONS: <br /> I <br /> ACCOUNTING ONLY: AID# °p QUEST# INVOICE <br /> R9C'D BY DATE PERMIT —II <br /> PECODEG FEEINFO AMOUNTREMITTED CHECK# f( 3 <br /> mol MIf3 — CAS Cc�n <br /> Cr57.ZICEN5IDCONTRACTOIi'''Iv17STSZGI�T:ZICENSEEES'' ly)pFNS ' ONI)ECLAR1ITION <br /> Q <br /> UNIT TV-6/23/99/5,gn bkpg/MI ot/AAN I P <br /> -fi---g1r02/2000 iFii: 12:11 ITb/RS NO 6378J 0.003 <br />