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FIFTH FLOOR PAGE 03 1O <br /> r[oI [elurJ nG: [:; LYJy4bti ;43� v <br /> • <br /> WELL PERMIT APPLICATION FORM UNIT' l;l_1I; ON <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICM U3 J,'_!! I ( PM 1: 49 <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 3D4 E. Weber, Third Floor, Stockton, CA., 95202 FILE CQPY <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES t YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin Cou our 9-t tr75. and the Standard sor nof San Joaqimwt uin n County Publicc Health ed. This application <br /> Environmental ntaade in all compliance <br /> Division. <br /> San Joaquin County Development Tale, P Assessor's <br /> WELL Location 23564 S C"-Aa Yc�"� _Cross Street <br /> ehY RzoexeaNw Zp153107 parcel# 249-070- otz <br /> # Fw.<:�u Zi 99109 Phone#4h y40-1Uy7 <br /> PROPERTY Owner nU ANN»r A1�-�uor( Address/d;7 0`Farel. 54w+ 10 CiIYS_ P— <br /> C•67 Contractorz) <br /> Address 3133?f— zsc. R�Bf3—GitYZip(5742 Lids 5544747 Phone#x-636-7174 <br /> cPrnlZ c T.,�crnnitwrK�Address3011 W:6c 31'1 :k l� Cftyr rlwlc•alcwLlc# Gl62 Pnone#`n� ` 'OYDll <br /> Consultant!Sub Contractor Ear j- Section 2 N <br /> .t ,Township -?i So..kh Range_4 <br /> GIS Coordinates:X�---� <br /> WORK TO BE PERFORMED below) <br /> �DESTRUCTION(choose type . <br /> ( NEW WELL!BORING(CPTGEOPROBE,HYDROPUNCH, <br /> jHAND-AUGER,OTHER') 13 OVER-BORE <br /> %O1L SORT 1c v 58-I a PRESSURE GROUT <br /> ®'WELL#_ etWi - <br /> 'other­ -- <br /> COMMENTS: <br /> a <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS MULTIPLE CASINGS?o YES 8 NO{,�W,�ELL CASING DIA:z <br /> MONITORING HOLLOW 57EM DIA.OF BOREHOLE 41G TYPE OF CASING: 0 S7FEL t{rvG OTHER: <br /> 0 EXTRACTION Q AIR HAMMERIDRNEN CASING THICKNESS <br /> U VAPOR p MUD ROTARY DEPTH OF GROUT SEALTREMIE TYPE TO BE USED: AUGERS OMOSE <br /> PUSH POINT GROUT SEAL PUMPED: O Yes o (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> UAIR SPARGE a p I30L7EPTRAFFIC BOX or []STOVEPIPE <br /> p SOIL BORING 0 HAND AUGER CONDUCAPPROXT BORING DEPTH 0 iratlons here): <br /> — <br /> a OTHER: <br /> D OTHER CONDUCTOR CASING PROPOSED? (M YES,list sperJf <br /> �YarJ't}t ✓7<dC <br /> COMMENTS: 138-1 Wall he.wtll,ze v 75 F1 }l e. .. <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I herehy certify That I have prepareles <br /> d[his app!Hobo delh� tensed egntsds gnature flea the ll wing:-1 eerdfy rhan J 0[in the�pulormanee of the work <br /> and Regulations of the San Joaquin County. <br /> ring or sub <br /> for which this perm![Is issued,1 shah not employ persons suDJect!o WORKERS'COMPENSATION Laws ofed.I shall a Contractor's <br /> ns sub' U to <br /> contracting signature certifies the following:'1 certify bra!In the performance of the work for which this Parma rs issued.!shall emp y pe /e <br /> WORKERS'COMPENSATION Laws of California." <br /> GSiRs'IN'ADYAW_CEFOit,g�f C ,ViREMINAP� Wall <br /> CAL',l.p ...�J�Nk7�`1)'l�fdS,`P'ECTOR:48,1.NAItI�I,� <br /> n-� ( 1 TidelCompany SeCoit- 1.,Ae n",�'iu.ntt�1 7 x-hC <br /> Signed x <br /> 7-10- <br /> �ar RTD c.l.�cr 4,rnzt r1o2 Pn:>;el Mwrre9er Data 6b <br /> Print Name I_ <br /> DEPARTMENT USE ONLY -7 <br /> Date Issued / "-1 3 �d0 Area FTU T <br /> Application AceePled ByDate Final inspection By Dete <br /> Grout Inspection By <br /> Destruction Inspection By Data <br /> COMMENTS I CONDITIONS: <br /> R <br /> ONLY: AID# <br /> FEE INFO AMOUNT REMITTED GHEGK B RECD BY DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> � (pI 22�- 1-13• 0 23 -3 ine/z000 <br />