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04/28/2000 08 23 2094663493 FIFTH FLOOR PAGE 03 / <br /> WELL PERMIT APPLICATION FORM UNIT IV g <br /> U <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) Coo hDCD <br /> 304 E.Weiser, Third Floor, Stockton, CA., 95202 <br /> (209)46$-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 9 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct andlor rnstalt the work desenl3ed 1-bis application Is made uF compilanoe wrth <br /> San Joaquin County Development Title,Chapter 9-11 iS 3 and the Standards of San Joaquin County Public Hearth Services Environmental Health Division <br /> Ft <br /> WELL Location 2 3? .,{- <br /> O t S. so ti,cross Street City QrukAbW .k Zip 75'75'36-736Patel#t `f4— 0(00— 01 L <br /> 9 5S 5 !�.-i-I""'PEAW.l 4 5(043 <br /> PROPERTY Owner:3/1,m C P i P 4dress X3'70 1 S. �� Qct CrtY .. ip �7 Phone# <br /> C•I57Contractor lresLi ll,h _ __,Address Lif,Iz.tcnct21 5u c �i GRyR wlb�ks,Z�p�57�1L L 4 Phane#`lG SG1-727� <br /> ConsultantlSubAddress300K-6c­?A 'k 4 1— Cltyila-d,. 2 Pncnc*l! <br /> GIS Coordinates X Y Townrhrp_ eve -_ Range E&J""r- Section Z <br /> WORK TO BE PERFORMED <br /> ANEW WELL/BORING(CPT GEOPROBE,HYDROPUNCH,HAND-AUGER OTHER-) 0 DESTRUCTION(choose type below) <br /> SOIL BORING# 0 OVER-BORE <br /> _WIVELL# &&h2 0 PRESSURE GROUT <br /> 'Other <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> I7�ITORING ••.-� HOLLOW STEM�� DIA OF BOREHOLE " MULTIPLE CASINGS7(]YES_NO WELL CASING DIA Z,r <br /> RACTION Q AIR HAMMERIDRIVEN CASING THICKNESS�O TYPE OF CASING p STEEL PVC t]OTHER <br /> o VAPOR d MUD ROTARY DEPTH OF GROUT SEAL / TREMIE TYPE TO BE USED ,AUGERS NOSE <br /> fl AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED %Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> p SOIL BORING p HAND AUGER APPROX BORING DEPTH W% BOLTED TRAr—Fic BOX or Q STOVE PIPE <br /> 0 OTHER n OTHER CONDUCTOR CASING PROPOSED? &6 (it YES Est specdicatlons here) <br /> COMMENTS: Av a' LjiyS <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby ceraalr that I have prepared this appticabon and that the work will be dom In accordance with San Joaquin County ClNnUnaes.State Laws and Rubm <br /> and Regultnniona of the San Joagstln County Homcowner or goanaed egenCs sginatum certifies the tbuowing:`t careWy drat in sere Pia of the work <br /> for which tors permit is rssrra4 t ShaU not emptay persons subleet to WORKFRS'CGKPfKSAT1CW Laws of CWfwnta" ContradkWs hiring or sub- <br /> oontradtng signature certYles the following-'I c+etbyy ural in rhe pedbrmanee of the work for which this permit as issued t shad employpsrsans subbed to <br /> WORKERS COWENSA770N Laws of Calr7wWa <br /> _CAL,V ,1 1 1 1 '%"09i 040R,4&W,0%(W IN A©VANIGE".4,A=t RED;- �1� I . � <br /> Stgrned x <br /> L tI'�G lL[hL TEde/Company } ✓ StzlJ7i2 7x-bC+-na <br /> Pnnt Natne to <br /> OEPARTMENT USE ONLY Q <br /> AP9Gahnn Aooeptzd By <br /> Date Issued <br /> Grout Inspection By 4 Inspection By Date <br /> Desirdedon Inspecum SY Date <br /> COMMENTS t CONDITIONS <br /> tC01PE 'ITING ONLY AIDS <br /> ]ESFEE INFO AMOUNT REMITTED CHECK 8 RECDSY DATE PERMITSa`RYlCB REQUEST At INVOICE <br /> 2.3-4 ?- <br /> 1/1$/2000 <br />