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04/26/2000 00: 23 2094683430 FIFTH FLOOR • FILE <br /> IL AF1 0 <br /> _ UNIT IV <br /> WELL PERMIT APPLICATION FORM r� <br /> S' SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES DT L&� <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor,468,W9�n, CA., 95202 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Ircatian FS made in compliance with <br /> Appocadon is hereby made to San Joaquin County tar a permit to construct and(or install fire work�5crilic This app onmen Oi s <br /> San Joaquin County Development Tile,Chapter 31115.3 and the Standards Of San Joaquin County Put Health Services. Environmental Health Division. <br /> / r nnI /1,,.,.�,r.,,k Zip 9S36T Parcel# 2'f`l^070�00� <br /> ^ 3 FOGS 5 SGn{'4 Fe FLt-Cross Street city WELL LOcatlon a f �ul ^ ip 957 Phone#2e9-Y61-ay <br /> PROPERTY Owner rfl <br /> AOL, Atldress2 i(�loS S l" FG �•City Ma f. Z 3%1 <br /> -zz Rt - l- 21 ic6 CitYPn„Jw Zip <br /> gS74L Lic#.f5YS797 Phone#4u' 63$-7L7(r <br /> C-67 Contract() Lk-L Hoz rk Atltlress 4lL !-oyo� <br /> Sv. i� CI 2a.,di,.L,•.I...n Llc# �/dz' Pnone# <br /> Consultant!Sub Contractor 5'rLL Z%?_ rn�r�"�"'k Address3-� �l R� ry Section 2�j <br /> GIS Coordinates:Xf— Y�—�_ <br /> Township 3 S`—Range `�� S�— <br /> WORK TO BE PERFORMED a DESTRUCTION(choose type below) <br /> )'NSOIL BORING WELL!BORING(CPT, OHYDROPUNCH,HAND-AUGER.OTH p OVER-BORE <br /> U SOIL ORINWNG C a PRESSURE GROG <br /> SWELL 4 <br /> •Other 'yam <br /> COMMENTS: / �'L{CnllOr,• uJcLl �• [KA, <br /> CONSTRUCTION SPECIFICATIONS <br /> TYPEOF WELL INSTAL- ATIO_N TYPE r' MULTIPLE CASING57 BYES *NO WELLCASING DIA:? <br /> )OONITORING -AHOLLOW STEM DIA.OF BOREHOLE <br /> U <br /> EXTRACTION G AIR HAMMERIORNEN CASING THICKNESS SCS'• ND TYPE oREM E TYPE TO BE USED' AUGERSR NOSE <br /> VAPOR p MUD ROTARY DEPTH OF GROUT SEAL !(d <br /> PAIR SPARGE PUSH POINT GROUT SEAL PUMPED:'j,Yes ONO (NOTE oAITRAFFIC BOX oLLRDEPOTVEHIS <br /> SED') <br /> p SOIL BORING p HAND AUGER APPROX.BORING DEPTH yC--- specifications here): <br /> II OTHER' R OTHER <br /> CONDUCTOR CASING PROPOSED7�(k YES,IIs[ <br /> COMMENTS: o W'q I1 <br /> 0` S <br /> NOTE OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby certify that 1 have prepared this apPl Homcawne o Incensed Wllents gnalure cenfiiea the (Slowing:-1 cerary thatuin County l � RolesTS—t7te Laws—and <br /> inthePerformrance of the work <br /> and Regulations of the son Josquln County. fo ns subject to yVORI(ERS'C04fPENSATION Laws ofed.I shall employ <br /> Contractor's arsons sub subject to <br /> ling or sub- <br /> for wfrich fhis permit la issued,l shell not amp Y Pe+SO <br /> wntrading signature certifies the following:-f cerb'fy tl7af In the perfgrmanca of the wok for which this Permits issued.!shall em oY!» <br /> HFt&IN'ARY1g14CE1PORALL'; f2EQk71RED IPIS,P�E31Qk15 <br /> WORKERS'COMPENSATION Laws of Cahlomra." . <br /> CALLI016 �f1PECTOR:48fYV4k [[l P okcl Mangy e� S�fDZ 7 h{e�nh�i� H� Ti <br /> TNe1Comp3ny <br /> Signed x I <br /> rW1.TC• Data -7-11700 <br /> Print Name y <br /> DEPARTMENT USE ONLY 7[ Od Area 6(,Y( y <br /> Date Issued <br /> AppllGation Accepted BY Date <br /> Dare Final Inspection ey <br /> Grout Inspection BY Data <br /> Destruction Inspection By <br /> COMMENTS f CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> RE Y ���— PERMIT(SERVICE �QREQUEST# INVOICE <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKS 2 <br /> 3�( £s`I� 101232 i/>aizooO <br />