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��� �� • r FILE COPY <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES wn <br /> AUG 15 2001 ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E.Weber, Third Floor, Stockton, CA., 95202 <br /> ;�1- <br /> ENVIRU?diN I hfALTh' (209) 468-3449 <br /> PER�Vi;TjSER Vi CES <br /> ON-RFfUNDAI I I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Applicatlon is hereby made to San Joaquin County for a permit to con stmd andfoI install the work described. This application is made in compliance with <br /> San Joaquin County DDevelopment`Tule,Chapter 9-111115.3 and tthe Standards of San Joaquin County Public Health Services, Environmental Health Division. <br /> WELL Locatler 1860 —Oz•� `� """ar tr e � i L1:Cty /tLG/i( Zp' 3 Parcel# /p <br /> / y,�O /��OO Sn�sc�olib�J 7 — p9 7 823- 3/2 <br /> �,//a//py/ CLQ Z,i$�� Phonee/R[� 1 <br /> PROPERTY Owner R/il i✓ Address �'�-"� cX -"79 fish« 63g- 72 7/a <br /> �d� �,�- � ,�,mz ://A ess Cil 96�Li Phc <br /> C•57 or ./ <br /> Address = 4 i° CH < <br /> Y�t11=Llc# Phone# S <br /> onsultanl I uD Contractor �7 � L <br /> GIS Coordinates:X ,Y ,Township Z s Range / L Section b -1 <br /> WORK TO BE PERFORMED Cc' Ill d P� Sa 2 p <br /> 'PO-273 <br /> WORK <br /> U NEW WELL I BORING(CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER-) Y DESTRUCTION(choose type below) <br /> U SOIL BORING k lkoVER-BORE <br /> WELL 1RESSURE GROUT <br /> -other: �,A / - ` <br /> COMMENTS MSN YI�I,(I - 2, b � i ytq f�[/JIR.G d� {� 6971251LrUGTI0YI <br /> eKrS�l,> qqa � bc�1/�/y � -S(See 5,7� 'V/) <br /> TYPE OF WELL INSTALLATION TYPE A CONSTRUClf[ON SPECIFICATIONS <br /> `MONITORING U HOLLOW STEM DIA.OF BOREHOLE /O c, MULTIPLE CASINGS7 0 YES ONO WELL CASING DIA: <br /> U EXTRACTION U AIR HAMMERIDRIVEN CASING THICKNESS 5LG 4o TYPE OF CASING: 0 STEEL PVC OTHER: <br /> U VAPOR U MUD ROTARY DEPTH OF GROUT SEAL z TREMIE TYPE TO BE USED: XAUGERS UHOSE <br /> U AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: i(Yes U Noo�(NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> U SOIL BORING U HAND AUGER APPROX.BORING DEPTH -5n X-J e/ U BOLTED TRAFFIC BOX or U STOVE PIPE <br /> U OTHER. OTHER CO DUGTOR SIN2 PROPOSED? (if YES,list specifications here): <br /> ZZ- <br /> 11 r <br /> COMMENTSr r <br /> c - e7 ` - <br /> NOTE: OFFSIT BORINGS REQUIRE ACCESS OR ENC OACHMENT PERMITS <br /> I hereby certify that I have prepared this application and that the work wr11 be done In accordance with San Joaquin County Ordinances,Slate Laws,and Rules <br /> and Regulations of the Sen Joaquin County. Homeowner or I'rcansed 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 penuns sublett to WORKERS'COMPENSATION Laws of Cillifomla." Contractors hiring or Sub- <br /> contracting signature certifies the following:T certify that in the peAamence df tho work for which this permit is Issued,I shelf employ persons 4suubject to <br /> WORKERS'COMPEN TION Laws of CaRfom IRED7IN ysg5' <br /> 9►LL` - t....�(si QR.. tIN AR1lSI�I�als .1 <br /> i ' / <br /> Signed z CGe- 7dle/Company <br /> '2��A� <br /> Print Name Date <br /> DEPARTMENT USE ONLY Q /� <br /> Application Accepted By Date Issued ! • �� Area <br /> Grout Inspection By Data Final Inspection By Date <br /> Destruction Inspection By Dale <br /> COMMENTS I CONDITIONS: <br /> My <br /> Dff <br /> MOUNT REMITTED CHECK M RECD BY GATE PERMIT(SERVICE REQUEST i INVOICE <br /> 2.7-7 Z <br /> 1/18/2000 <br /> ZR 39tid 800-IA Hl-3I-:I £EVE89460L LI 000Z/9Z/40 <br />