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04/28/2000 08:23 2094G83410 FIFTH FLOOR • PAGE 03 79 <br /> COP <br /> WELL PERMIT APPLICATION FORM UNIT IV, I ,I <br /> ON <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICED X, ( I .per ): 49 -� N <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 GATE ISSUED <br /> Application is hereby made to San Joaquin County for a permitto construct andfor install the work described. This application k made in compliance with <br /> San Joaquin County Development TNe,Chapter&1115.3 and tha Standards of San Joaquin County Public Health Services.Environmental Health Division. <br /> Assessor's <br /> tZ1utt0*Jit T 15367 Parcel# 249-070-01z- <br /> wELl Location77Sra 5 Saa� to 170 Cross Street City P <br /> PROPERTY Owner t)o A%N- Al"-�000Z Address 6067 O'.Ca l Sf mi$'10 Citysm F.o..cttc. Zip 94/0 Phone#Hct y40-1047 - - <br /> 7s9�7A i57o <br /> FitcM eK�,.o.•me.+�wl __ 399 SherYr PWrr. _ Vo-\\w 5>'n rFt 9 232 683865 - - <br /> C-57 Contractor __Adtlress __ChY'Zip.- Lid-L- 'hone#' <br /> .>`a . R,I.S�:kIW Clty2etI, (G•d�LIdF 6102 Pnone#576 [-OYoU <br /> Consultant?Sub Contractor 512(01- 1:-wK�Address?Otl k:leor• <br /> GIS Coordinates.X .Y ,Township 3 5w Range, 9 EAs')- Section 2 y <br /> WORK To BE PERFORMED <br /> aNNEW WELL I BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) Q DESTRUCTION(choose type below) <br /> OVER BORE <br /> p/SOIL BORING# GP- L G�'3 Q PRESSURE GROUT <br /> Q <br /> 'Other. FJSkWAk deet 'WELL#P -- <br /> COMMENTS; <br /> TYPE OFWELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS �/ <br /> MONITORING rfOLLOW STEM DIA.OF BOREHOLE <br /> MULTIPLE CASINGS?Q YES a NO WELL CASING DIA:— <br /> Q EXTRACTION Q AIR HAMMERIORIVEN CASING THICKNESS S �__TYPE OF CASING: Q STEEL �eVC `J OTHER: <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: AUGERS BHOSE <br /> 0 AIR SPARGE PUSH POINT GROUT SEAL PUMPED: Q Yes (NOTE:MAXIIDMUMFFR BOX oLLQDEPTH IPE 0' ) <br /> 501L BORING Q HAND AUGER APPROX.BORING DEPTH_0 <br /> aCONDUCTOR CASING PROPOSED? (M YES, list specifications here): <br /> Q THER: D OTHER <br /> COMMENTS: - \(rel {o q5 ir,� 4JV Gr " 6"kdji� G,,,"GP-2 GP-3 lxcly <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> and Rules <br /> I hereby cenny that I have prepared this application and that 11 the work will be done In accordance with San Joaquin County Ordinanrperes.Stale Lae offhe work <br /> and Regulations of the San Joaquin County. Homeowner ce <br /> or Iloensed agent's signature rtifiea the following:-1 card *hat in the perforrtran <br /> for which this Permit Is issued,I shad not employ persons subject to WORKERS'CoATPENSAVON Laws of California." Contractor's hidng or sub- <br /> contracting signature certifies the following:'I cerh'fy that In the performance of the wok for which this Permit is issued.I shall employ Persons subject to <br /> WORKERS'COMPENSATION Laws of California." <br /> GAL4'T f I k I C . ..it0- R_4$I4N E [,Nai3RS'.IN'ADVINWC.119 1 LZ„�S�LI�REQ,t71(RED' PC i3IO!(S <br /> TIdelCompany 'Je(07-- 1�^-Ter r�u.tor,l 7 Ike <br /> Signed x <br /> -ft <br /> fnt lhCr Ivvr.� P <br /> t F"x ivr-e1 A( .Uol0-bo <br /> Print Name �a� C� e, Date <br /> r,n.. <br /> DEPARTMENT USE ONLY <br /> Date Issued-7— 13 ^oU <br /> Application Accepted By Dale Final Inspection BY Date <br /> Grout inspection By <br /> Destruction Inspection By Date <br /> tio <br /> COMMENTS 1 CONDITIONS: <br /> :PE�CODES <br /> OUNTING ONLY: AID# <br /> 612E INFO AMOUNT REMITTED CHECK A RECD BY DATE PERMIT I SERVICE REQUEST It INVOICE <br /> S 1012?-� Q1, 7-13 Qu 120,9030'd 1/1812000 <br />