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03/20/2000 10:15 2094683433 FIFTH FLOOR PAGE 02 <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 DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made In compliance with <br /> mental <br /> San Joaquin County Development Title,Chapter 9-1115,3 and the Standards of San Joaquin Caunry Public Health Services,EnvirA sessoes Health Division. <br /> �/nSYrwG-2.+ Cit ScsKYonr zlp4T206 Parcel# 145-030-JO <br /> WELL Location 2' 9+7 /VA✓ 27)Zt✓E Cross Street Y <br /> PROPERTY Owner <br /> J`-F�� L !? dress POO%ow✓clr t.OVr+7ky RD City C�RAr'GE Zip9Z868 Phone# 71¢-$60- 457`/ <br /> Me 4 '742 / 853-e010 <br /> C57 Contractor TEG Address 11350 ^*G ,eft �n Rrr �.City :.RvyA Zip LigF Ph°ne# 6- <br /> 4080 CAW- 577 "u '.Al GRA.•rrc Lic# Phone#916-786-0320 <br /> Consultant/Sub ContractorC� Le°"'{ TR"K£ Address City—A� <br /> GIS Coordinates;X <br /> Y.,Township Range Section <br /> WORK TO BE PERFORMED V101 <br /> DESTRUCTION(choose type below) <br /> k EW WELL I BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER, OTHER-) 0 OVER <br /> •g SOILBORINGY 4E -1 'r* GP•Q <br /> # PRESSURE GROUT <br /> p WELL <br /> 'Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> o MONITORING I]HOLLOW STEM DIA.OF BOREHOLE I rr MULTIPLE CASINGS]Q YESNO WELL CASING DIA;r n <br /> � <br /> B• TYPE OF CASING: %STEEL p PVC a OTHER: <br /> a ROTA <br /> VAPOR p MUD ROTARY DEPTH OF GROUT SEAL <br /> Q EXTRACTION AIR RIORIVEN CASING THICKNESS r 30=r�7L Fncc' TREMIE TYPE TO BE USED: 0 AUGERS HOSE <br /> 0 _ <br /> p AIR SPARGE PUSH POINT GROUT SEAL PUMPED: XYes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING D HAND AUGER APPROX.BORING DEPTH 30' 1]BOLTED TRAFFIC BOX or u STOVE PIPE <br /> U OTHER—9 <br /> OTHER CONDUCTOR CASING PROPOSED? -1A (if YES.list specifications here): <br /> COMMENTS: Gc^OPaoBE Soli. 3oRjr+6S <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, theand Rules <br /> and Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: "I certify that in the performance of the work <br /> for which this permit Is issued,I shall not employ persons subject to WORKERS'COMPENSATION Laws of California." Contraclnr s hiring or sub- <br /> contracting signature certifies the following:'I certify that in the performance of the work for which this permit is issued, I shall employ persons su0jset!o <br /> WORKERS'COMPENSATION Laws of California.' NCE'FOR•ALL f[GQUIREq.INISPECTION$. <br /> ,CALL'THE+UN 1V IN CTOR 48 WORKING°HRS IN ADV/t, <br /> -- TltleJCompanysrx. J;RorE.'r R°Gcoco6� LFR Lrvr".c•tRlefec= <br /> Signedx �" <br /> ScoTi /9. A7Zh5 or-rG Date J &� <br /> Print Name <br /> Jy <br /> DEPARTMENT USE ONLY <br /> ` Dateissued � tly Area <br /> Application Accepted By Date <br /> Grout Inspection ey r at(1e'��Fin I Inspection By <br /> Destruction Inspection By <br /> COMMENTS I CONDITIONS:,_ <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNTREMITTED CHECKS REC'D BY DATE PERMIT I SERVICE REQUEST A INVOICE <br /> J2 <br /> 1 / () <br /> Y/18/2000 <br /> MAR 20 '00 10: 15 � ` � 5 lt� 2094683433 PAGE.02 <br />