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Cori <br /> _, UNIT IV <br /> WELL PERMIT APPLICATION FORM <br /> AUG 1 5 2001 / <br /> . .,,11TH SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES aw i /, : <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) 111 <br /> "`I Cts 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 wnstruU andlor install the work described. This application is made in compliance with <br /> San Joaquin County Development Title,Ch'apt'1er 9-111155,3 and he Standards of San Joaquin County Public Health Services,lEovirAonssesstorl..S5Heayylth Division. <br /> /YI(t�'( R EW R SQL Z QS / Pani! 1�7:�/� fit/ <br /> WELL Locatlan —Z Co Sleet L7 ` City p <br /> `7y City 5?" Zi f4 Phone#ll 3/Z� <br /> PROPERTY !!� tIk aa/ Address 0 S <br /> (C- ct C tr� �I/ <br /> ' Addres r Ipg�Li Pho���i--�C7 70 rz c� <br /> AddresaZd ZSC MtC)7,g L4. City LIQ# P o9e <br /> Consulta I.f Sub Contractor '' <br /> Township _S 7Range_rr�� &�` Section <br /> GIS Coordinates:X Y <br /> 11 <br /> 51)ec RK TO BE PERFORMED Q ,/)fid g�V� �l ZO —���"Z��l �a' � `( 9/� <br /> ev 7 Q DESTRUCTION(choose type below) <br /> V NEW WELL/BORING(CPT,GEOPROSE,HYDRO 'INCH.I AND-AUGER,OTHER') U OVER-BORE <br /> �f -'SOIL BORING 00 PRESSURE GROUT <br /> •Other: S'ee a c )aa( <br /> COMMENTS rp�RcPiY�an{�UI.�I�Sa�eff J' Z� <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 7 <br /> MONITORING *HOLLOW STEM DIA.OF BOREHOLE_MULTIPLE CASINGS?0 YES NO WELL CASING DIA:L <br /> TYPE OF CASING: 0 STEEL ` PVC O OTHER: <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS—TREMIE TYPE TO BE USED: AUGERS OHOSE <br /> 0 VAPOR a MUD ROTARY DEPTH OF GROUT SEAL N <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes No OTE�J:BOLTEO T�FIC IC BOX or (I STOVEPIPE O'I <br /> 0 SOIL BORING B HAND AUGER APPROXCONDUCTOR BORING DE PROPOSED? (AYES,list specifications here): <br /> 0 OTHER: n OTHER <br /> 2 ZZ <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby certify that I have prepared this appllratlon and that the work will he done In accordance with San Joaquin County Ordinances,Slate Laws,and Rules <br /> !or which thisspermlt is lssued,rl shat?rpt emP of YPenon sub/ecf fonWOlt/CERS'COMPENSAiIONnLaws of Calitomia., Contractors hiring or sub- <br /> contracting signature ceAlfies the following:"!partny that in the performance of the work for which this permit is Issued,!shall employ persons subject to <br /> WORKERS'COMPEN TION Laws o(Cafifdmla 7N'......................1Di'117,..................yS1ls� aws9IRE��IN $p <br /> grad <br /> TNlelcompany Dale 641-0 / <br /> I/ <br /> DEPARTMENT USE ONLY 9 /���/ NMI <br /> Y' <br /> UU Date Issued ` Area <br /> Joh <br /> lirahon <br /> Ply By Date <br /> IGrout inspection By Date Final Inspection By <br /> i1W,-Destruction Inspedi n By Date <br /> I COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY OATS <br /> PERMIT!SERVICE REQUEST# INVOICE <br /> �� �• S2 Z?' ' 6�W P-15 <br /> Ina/zooD <br /> Z0 39vd a003d HIAIA EEVE69PGGZ TE:tT 000Z/9Z/b0 <br />