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04/28/2000 06 29 2094683433 FIFTH FLOORU01I� AGF 03 q <br /> � o <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES D <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 DATE ISSUED <br /> Application is hereby made to San Joaquin County tar a permit to construct andfor install the work descried This application Is made u+compliance with <br /> San Joaquin County Development Title,Chapter 9-111/5�3 and the Standar4s of San Joaquin County Pubic HeaM Services Environmental Health Division <br /> 3rO�,S 5 Scn[�Ff f<4 Cross Street City /2LU�GtI�J dk Zip 95�G7 ParcelAssessor <br /> r <br /> WELL Location c• <br /> PROPERTY Owner <br /> r-O r{tel". AddressZ S f. r 15C 9r City gj f&,�,Z[p y5_ 37 Phone#Zc4 Y6f-ZGy3 <br /> C.67Contractor lJc4lhAz n,� <br /> address3�3 Fid c+r� CRy 4, Zip!2gz Lic#S5Y0i 77 Phone# d- Gat:-7276 <br /> Consultant l Sub Contractor SZLCi2-Sw rnAV`42 tt Address k t re,R Sv k lcvtY <br /> GIS Coordinates X Y Township 3 51111w, Range q �1ts �' Sec3ion Z�1 <br /> WORK TO BE PERFORMED <br /> XNEW WELL J BORING(CPT GEOPROSE,tiYDROPUNCli,HAND-AUGER OTHER-) a DESTRUCTION(Choose type below) <br /> SOIL BORING p OVER-SORE <br /> p <br /> 3 SOI L# PRESSURE GROUT <br /> 'Other h <br /> COMMENTS / /vo,tfa re tJv�r <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ITORING )tHOLLOW STEM 01A OF BOEiEHOLE ri MULTIPLE CASING57 p YES , NO WELL CASING DIA Z�1 <br /> TEiACT10N Q AER HANpNERrDRIVEN CASING THICKNESS cE—TYPE OF CASING 0 STEELfG p OTHER <br /> VAPOR d MUD ROTARY DEPTH OF GROUT SEAL 6 TREMI£TYPE TO 13E USED RAUGERS *OSE <br /> 13 gAIR SPARGE PUSH POINT GROUT SEAL PUMPED Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH !S 30') <br /> p SOIL BORING 0 HAND AUGER �NRD�JCTaR CASING PRPROPOSED�{N YES list spec�i ClonBOX <br /> s here) <br /> ©STOVE PIPE <br /> 0 <br /> OTHER — a OTHfR <br /> COMMENTS: s W� '� O' S <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> 1 hereby certdy That 1 have prepared this app[icatton and that the work w[p be dome In acCordartce wth San.Joaquin Cotr[tt�r Ordinancias,State Laws and Ru <br /> les <br /> and Reguistiens of the San Joaquin t;ountY HorrtrwWMr or Deemed emu's signature cemfies the fiollov mr-7 cerrifq'that in fhepufarmarece of the work <br /> far which this permit is ensued,i shali riot efflPfcYPersatrs suWW m WORKERS'COMWENSA17ON Laws of CardambL" Contratd+or's h(rtrtg or sub- <br /> ooittracbng signature cer'd'tlt s the foAaMrig-`I catbyY thaf ler the Drrrformer4&of the want for which this permit ss issued 1 shall emAbY Persarls subject to <br /> Wl7Rlal:R3 COMPENSA7JON LaiNs d C Rbrrua' R,"IN ADV1NliC_ �C:� IRED;�f�fSP +'W 5+ <br /> Signed x TitlelCompany �^ a-� �vaN � S�CoR. �n TC�11d7�i��rst� �. <br /> Print Name rlut*t Date <br /> DEPARTMENT UDE ONLY Are <br /> Appf�atron Aceepteti By Date Issued <br /> Inspection By Dtite Ftna!Inspection By Date <br /> Destruction Impact=By Date <br /> COMMENTS f CONDITIONS <br /> COUNTING ONLY AM <br /> tO <br /> E GODEti f:EE INFO AMOUNT REMiTTF CHECK/ REC'D BY t7ATE PERIIAIT/SERVICE REQUEST!k INVOICE <br /> 10 Z3 2-- AW <br /> Z3 Dia <br /> 1/1812000 <br />