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s ORIGINAL <br /> �r <br /> Lc�hI�yrr1.L <br /> L�` UNIT IV <br /> WELL PERMIT APPLICATION FORM <br /> AUG 1 5 2001 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES to il <br /> t =iJT HEALTH ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> diijl5ERVICES 304 E.Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES'I YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to censtmd andlor install the work described. This blic Health Servapplices, <br /> is made in Environmental compliance with <br /> San L2 <br /> Assessor 55 <br /> San Joaquin Caunly Development Tide r 9-1115.31and fh fwo-A�Standards ofryc n1x�r Joaquin Caunry Pu/ Services, ParceY7'�e Y <br /> /G2flf r> �. _jj���o(S+vnsn sveat ,rr 7Q cdy 2 zip-90-3 s— p <br /> WELL Locatlo //--yy�� P9�Phone#!J 3IZ C <br /> �� 3✓K AVE //7. Address � S Ct�5549� 9 <br /> PROPERTY Owney�, � 1 i ^/ Lic# Phonelt -�rJ 3o 'ry27k <br /> cto i / Addres r cl Pl�/� <br /> yr� �rr C�lvl. ua# P209e#44P / <br /> r Address7�ZsC/Ol//-71e ��. City <br /> ;;t <br /> l Sub Contractor Sectlon =3 _ 4 <br /> Township--Z-S-Range <br /> GIS Coordinates:X -Y / c, /1 <br /> (Q C67Qd �Y���-�Uc ¢ 9 `F �U <br /> WORK TO BE PERFORMED Z -�(��� 731 Q DESTRUCTION(choose type below) <br /> Y NEW WELL I BORING(CPT,GEOPROSE,HYDRO I INCH,rAND-AUGER,OTHER') O OVER-BORE <br /> /q 1011.BORING# 0 PRESSURE GROUT <br /> WELL# olU r-//�e�/.✓7CiJ-�2- <br /> •Other: S-�e a )� <br /> COMMENTS: fQ}�IQCBIY)D1)�UILIIJ C3 y <br /> 7 I r <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICAT MUS MULTIPLE CASINGS?0 YES WELL CASING DIA:Z <br /> MONITORING %HOLLOW STEM DIA.OF BOREHOLE '�' _ <br /> TYPE OF CASING: Q STEEL `ED: Q OTHER: <br /> U EXTRACTION AIR HAMMERIDRIVEN CASING THICKNESS-C �TREMIE TYPE TO BE US/E'^D: AUGERS OHOSE <br /> VAPOR C MUD ROTARY DEPTH OF GROUT SEA N <br /> Q AIR SPARGE Q PUSH POINT GROUT SEAL PUMPED: Q Yas No OTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> !V'BOLTED TRAFFIC BOX or p STOVE PIPE <br /> Q SOIL BORING Q HAND AUGER BORING DEPT <br /> . CONDUCTOR CASING PROPOSED? r2 o (if YES,list specifications here): <br /> Q OTHER: n OTHER <br /> ZZ <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS RE4UIRE ACCESS OR ENCROACHMENT PERMITS <br /> u County IardrReguladonahof the Sa nJaequlben County'(Hoiriwownchar liven ed egenYe signature ce�rdRes 1ha followi 9 !�fY ro ia." Cin the P�O��ri ofthe or s ork <br /> b- <br /> contracting sgnalure certlges the folMwin I aartrry Nat in fhe peAormance of tha work for whfch Ihls permH is issued I shall employ persons subject to <br /> for wh(ch flt(s permit Is issued,I shat)not employpersans subfed fo WORKE'RS'COMPENSATION Laws of Gflfomia." Contndor's hiring or sub- <br /> g; <br /> WORKERS'COMPEN TION Laws ofCahfomia `IKIADS'�A4SI£+� IREp��t - Tel <br /> S5 <br /> G , TRIeiCompany Y�Y✓ (��!W(�1 --�/n . <br /> lined <br /> Print Name <br /> 5 <br /> U <br /> DEPARTMENT <br /> Date Issued <br /> Application Moon By BY u to/�52 <br /> Grout Inspection By <br /> Date Final Inspection ey <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# _ <br /> PERMIT!SERVICE REOUE57# INVOICE <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# RECD BY DATE <br /> O �. $2 2•-1�pT d C4,,W 1/18/2000 <br /> ZB 39yd 600-IJ HiJId £Eb£89b601 LE:bT 000Z/9L/b0 <br />