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t M0002 <br /> 11/02/2000 THU 12:41 FAX 916 i:� 4101 V W DRILLING INC <br /> SETTLER-F.`'/qN INC. F'HONL NO. 51r F31 1.17 <br /> 02 2000 11:21Fii9 P= <br /> FROM <br /> ILE . COPY WELL PERMIT APPLICATION FORM UNIT 1V <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 /> licalinn is made in comPhance wan <br /> NON-REFUNDABLE PERMIT EEPIREB i YEAR FROM DATE ISSUC EnvlrOnmental Healtn Oivsion.qq�� <br /> .AsSeSSOf a O,✓T-4) <br /> e-r 9-1115.3 and the Standards al San JCaquIA COun Public Health Scry i ny Parcetrr/.l9 24 <br /> App1{cation is Hereby made to Sart Josquin County Fnr a Dermlt to construct and/or install the work ty P,bed. is <br /> -fiz <br /> San Joaquin County Development Trtle,Cna." /1 "C,I ,..nT✓ Zip <br /> city��— <br /> /� C /'/✓c2 ___CrossStroet / ¢aPtl Pnoness /L _1����r <br /> WELL Location QA e7 r>z 7t'JO Clry1+'T_��Zlp LF/.S <br /> ncYo % Address /JLo9o¢phnna*�o� 7�9 <br /> PROPERTY Owner ,(�r�p 9f'T/Li <br /> Op a� r✓ _�aY� U�p nC9/6 G3✓ /7" <br /> 1/T� <br /> C-57 contraOtOrY �.��n.r„•.�.� -e �' p-. City7�- <br /> �-�'iw �pra�✓ T.G Address ,er Lac Secrion <br /> Consultant 1 Sub Conttactor� YownshipRange, --� <br /> � <br /> GIS Coordleates:Xf <br /> WORK TO BE PERFORMED a DESTRUCTION(choose lypd below) <br /> U OVER-BORE <br /> // WYDROPUNCH.HAND-AUGER.OTHERS a PRESSURE GROUT <br /> y�W WELL I BORING(OPT SOIL BOR NG U / U✓- .f� <br /> �rvELL1 � j y <br /> -Other: /� oC < <br /> COMMENTS: y CONSTRUCTION SPECIFICATION`'7IPLE CASINGS?a YES�O vVELI CASING Dia/ <br /> TYPE OF WELL INSTALS PE' /d�MUL S OTHER: <br /> HOLLOW STEM DIA.OF BOREHOLF � <br /> ONIYORING SlG Q TYPE OF CASING; a.TEEL VC a dtHOSE <br /> rTION a AIR HAMMERIORIVEN CASING THICKNESS e•>'e�eZc--J TREMIE TYPC TO M USED: 0 AUGERS i i <br /> a EXTRA (I MUD ROTARY DEPTH OF GROUT SEAL Ye�NOTE: MAXIMUM FREE-BALL DEPTH IS 30') <br /> �APOR OROUT SEAL PUMPED' jI oLTED TRAFFIC B0X or U STOVE PIPE <br /> .,AtRSPAROE aPUSH POINT C'c C?r2 <br /> a HAND AUGEP. APPRO%�BORING DEPTHII�- <br /> a SOIL BORING CONDUCTOR CASING <br /> PnO'OSED7 (if YES.liet spacifwtians here): <br /> a OTH511. a OTHER_� <br /> t fo c fib'` e <br /> ✓ lLJ1fi f/d o G7-°YJ Z vLrG/ T- Z. J <br /> COMMENTS: Z ✓ GVH /r r+�UGI. v <br /> CESS OR ENCROACHMENT PERM? <br /> TS <br /> NOTE: OFFSITE BORINGS REQU <br /> IRE AC <br /> !o orsons sucyee;to <br /> u. <br /> l0 orsons subjectda to WORHERS'eOMPENSA710 Lowc o1 California." Contractor's hiring or to <br /> ugtinn5 of the San Joaquin County- Homeowner ur licensed agent's signah�re certifies the following: "1 ceRlal that a.me performance of the Work <br /> I hereby cemry that 1 nave Prepared this application and that the work will ba done+n accordancehe f Sen Joaquin County Ordinance,orma awe, <br /> and Rap I shell not emP yPwork(cr which tors Permit Is issued,IShal!emP vA <br /> 1vr which this permit is issued. s In me Performance of rna <br /> amtracling signature certifies pie to4owing:'f ceNfy f bRK�NG:HRS•IN ADVANCE',EOR;ALL RE4tlIRED INSPECTIONS. <br /> WORKERS COMPENSATION Lows L)ST- mia. � Y /JA/--o <br /> THEA AN7:M111US///5���'CQLL.48;W . osm�— <br /> // � Tine 01_' <br /> Signed k <br /> UNIT IV WORK PLAN DATED <br /> SEE SITE MAP IN DEPARTMENT USE ONLY Area_� <br /> 1 t,� Da;?Issuetl ly.}s1J-�Dater <br /> Application Accepted 6, L Date- r^Fina1 Inspection By-------- <br /> Grout Inspection By —`Pala <br /> Deslrudiun inspection By <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AID0 D BY DATE PERMIT RVICE CQUL-'S <br /> FEE INFO INVOICE <br /> AMOUNT REC <br /> REMITTED CHECK4 I I Lr) I <br /> PECODES /� /1c (at- <br /> : 0 OX;MUSl.'P.FS�TCKN' RKERS• C" ION <br /> ";LIC IWO <br /> TF-ACT <br /> ( -SFITCENbEI> C <br /> L <br /> Uh1IT IV-6/?3/99)sign bkpg_/Ml rV <br /> Nom : SQ A Polo' 11102/_000 THI: 12:11 ITSrkS NO tiJi9] rG 002 <br />