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LGI LtIt1C1 U0 1 , 1YIJ4b�,:;4 ; , - i-iF ]H FLOOR <br /> WELL PERMIT APPLICATION FORM - " UNIT�?I/�{1 th <br /> ON <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICW ��<rl <br /> HEALTH DIVISION PHS-EHD y ' j I PH l' �+ � � <br />' ENVIRONMENTAL ( ) <br /> 304 E.Weber, Third Floor, Stockton, CA., 95202 <br /> (209) "S-3"9 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ApplEcaoon is Hereby made to San Joaqum County tar a perm4 to construct and/or install the work described Thls applicabon Is made in compliance with <br />'San Joaquin County Development Trt1e,Chapter 9-1115 3 and the Standards of San Joaquin County Public Health Services Environmental Health Division <br /> Assessors <br /> wELLLocabon2_3 S.Naw Fc E-&A Cross Street Cay RzutE840,1, Zp f53b7 Parcet# 2y9-070 012. <br /> PROPERTY Owner UuAx1», lklAddress 667 0For"l54w+-4/0 CatySaAF.,,,.c.su Zip 9y/oi Phone#±b- 0-161(7 <br /> C b7 Contractor Mks 1�azi.+at address 3133 r fz�e*.J #L3 City +clWlc� 4 Zip <br /> I <br /> 95742 Lich 5 47 Phone#9(G <br /> Consultant I Sub Contractor 1L _L, cev%Av—c�Address l7 I�1 ore lZ.(. S-te w Clty +ck�r<c-s�auxic# 6162 Pnone#Y/G NU-Oyey <br />'GIS Coordinates.X Y Township 3 So.+kk-ti Range9 E& Section Section 2 y <br /> WORK TO BE PERFORMED <br /> 1G/P4EWVVELL/BORING(CPT 9FOPROBE,hYDR0PUNCH HAND-AUGER OTHER-) Q DESTRUCTION(choose type below) <br /> [rSOIL BORING 0 S$-1 p OVERBORE <br /> U ELL#_ =6 d PRESSURE GROt17 <br /> 'Other <br />'COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS +( <br /> ITORING HOLLOW STI-M DEA OF BOREHOLEr� t _MULTIPLE.CASINGS7 p YES k(NO WELL CASING DIA z <br />' RACTION 0 AIR HAMMERMRIVEN CASING THICKNESS Scin D TYPE OF CASING 13 STEEL �C OTHER <br /> Q VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED AUGERS RHOSE <br /> n AIR SPARGE ©PUSH POINT GROUT SEAL PUMPED Q Yes a (NOTE:MAXIMUM FREE-FALL DEPTIi IS 30') <br />'a SOIL BORING 0 HAND AUGER APPROX BORING DEPTH_ 410 a BOLTED TRAFFIC BOX or p STOVE PIPE <br /> 0 OTHER_ ,p OTHE=R CONDUCTOR CASING PROPOSED? (1f YES list specs icatlons here) <br /> COMMENTS Sq-I W t( i-x�r }v 75�� �� �,ra..�c lcuc�t�r, y✓�� <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby oe"that I have prepared dui application and that the work will be done In accordance with San Joaquin County Ordmartaes State Laws and Rutes <br /> and Regulawns of the San Joaquin County Homcowner or ticenaed agents sigrtatwc eerurma the following 1 ceiWfy that in the performance ofthe work <br /> for which this permit Is issued,1 shalt not employ persons subject to WORKERS'COPAPENSATIOAF laws ofCalifomla" Contractors hiring or sub- <br /> contracting signature cmitrtles the following 'I certify mal In the porfarrrlanCB of the work for which this permit is issued l shall employ persons subject to <br /> wont<wRS COMPEhGA TION Laves of Califomra" <br /> =CAk�i ��7:�1�1�11>��tdSrP`EC7�R.�48}�.�>���I,�.��iRS"lN ADVAIiICE�I~OEZ`;�'L.f��REQ�iRED; �Ip�s. <br /> Signed x ad� 2 TltlelCompany S Ei GR 3 v��cr t'w� iu.act,� 1 L <br /> Print Name ]r� AUC_k�cr lUx:L tcn(z QriyGA Mitrte+OGr Date <br /> DEPARTMENT USE ONLY <br /> Apol,catian Accepted By Date IssuedT + �U Area C•{Od jf <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Impectton By Date <br /> COMBlIENTS I CONDITIONS <br />' 0UNTING ONLY AIDC{ <br />' cOflES FEE[NFO AMOUNT REMITTED CHECKS R€C-D SY DATE PERMIT l SERVICE REQUEST At INVOICE <br /> � � (p� �z�- ?-�3•oc, p 23 3 <br /> 1/18/2000 <br /> 1 r� f <br />