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02/08/2002 13:58 2994683433 FIFTH FLOOR PAGE 02 <br /> ' <br /> WELL PERMIT APPLICATION FORM UNIT IV <br />�tWI NI IHCAL111JpMA <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> 02fES- I � 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 FRl]M DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct andlor install the work described This application is made in compliance with <br /> San Joaquin County Development Tale,Chapter 9-1115 3 and the Standards %San J again County Public Health services,Environmental s Cr4Y hrl��. <br /> suk Wolk 308 14.G�1� �. 5pe. r`• M'r�� AOPCtity 71p RAS_ ParceY#p�ef <br /> WELL Location S 4CM E. Mi Cross Street <br /> 1lS�oec.� zip gCMPhonesig 37� al <br /> PROPERTY Owner t:� o K n Address �� N• ei�d4 5} City �o't�37�l-`�3ao <br /> C-57 Contractor IN Address Pio 0 3 6 City o Vick► p '��7I Licoll710i7 Phone# <br /> 31Vta do Cw.. Dc fl t 11 Phone##1t4��91–l3� <br /> Consultant l Sub ConUactor Usv � Address a Cltyz+anr�w�'�.+�+1,J� � <br /> G13 Coordinates Y <br /> Township Range Section <br /> WORK TO BE PERFORM <br /> �DESTRUCTION(choose type below) <br /> ANEW WELL I BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHERI n OVER-BORE <br /> SOIL BORING# –&(A g�GJ 0 PRESSURE GROUT <br /> �1NELL# + <br /> "Other <br /> COMMENTS o 4 <br /> TYPE OF WELL INSI ATION TYPE COTl5TRUCTION SPECIFICATIONS WELL <br /> iTORING HOLLOW STEM DIA.OF BOREHOLE 8`r �JOULTI PE OFPLE ASINGNG13 p TEFL V.�'VC Q CASING��iA 2 <br /> dREFRACTION p AIR HAMMERIDRIVEN CASING THICKNESS <br /> (]VAPOR 0 MUD ROTARY DEPTH OF GROUTSEAL-15,60,rr° ro3 TR>=MI>E TYPE TO BE USED. AUGERS DOSE <br /> OAR SPARGE0%QNG O PUSH POINT GROUT SEAL PUMPED Ayes O PC e /aOTE SOA7FD QFC BOX�orLDEPTH IS O 7OVEPIPE'} <br /> SOIL BORING (]HAND AUGER APPROX BORING DEPTH <br /> p OTHER OTHER CONDUCTOR CASING PROPOSED? 1' o I(if YES.list specifications hero). <br /> 103 <br /> COMMENTS <br /> o 'T <br /> OTE: OFFSITE BORINGS REQUIRE ACCE S OR ENCROACHMENT PERMre�S <br /> ounty Ordinances, Laws,and Rules' <br /> I hereby certify that I have prepared this application and that the work will be don,in accordance with San Joaquin C <br /> and Regulations or the San Joaquin County Homeowner or licensed agent's signature certifies the following."I certlfY#011"the POftrmance ar or l sub- <br /> for <br /> u� <br /> for which this permit is Issued.l shall not employ persons subject to yyORKERS'COMPENSATION Laws of CalHbrnl*." Contri,ctors hiring <br /> contracting signature certifies the following 7 cerWy that In the performance of the war*for which this permit Is Issued' t shall aa►P1oY Aersons to <br /> WORKERS'COMPENSATION Laws of Callfomle" A VR ��� 'j� �1 <br /> T ;` f�ANT CPM448-z- �,?RI�INPF +1 : .. k� � �J <br /> c.,irw - _—t64-- Da <br /> Lry <br /> te <br /> Signed x <br /> SEE SITE MAP IN UNIT IV WORK PIAN DATED: <br /> DEPARTMENT USE ONLY <br /> Date Issued <br /> Application Accepted By Iftlr Date,—. <br /> inspection SY <br /> Grout Inspection BY, <br /> pale Flnal <br /> . <br /> r f � <br /> Destruction Inspection By Data <br /> COMMENTS I CONDITIONS. <br /> IPE <br /> CCOUNTING ONLY AIDS <br /> CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE <br /> REQUEST* <br /> INVOICE <br /> L �Q • S �� sus -y a - + <br /> r- <br /> F <br /> UWITIV-6/23/99/sign bkpg/MI <br />