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94/26/2009 9E 23 2094663433 FIFTH FLOOR PAGE 93 <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES � IL <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) a <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) "8'W9 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described This applwation ts made ui eompilanoe with <br /> San Joaquin County Development Tittle,Chapter 9-1115 3and the Standards of San Joaquin County Public Health Services Environ nntoal Health Division <br /> WELL I ooation 2-3 tySQ S SG.n4k Ge "Cross Street City�cirt n Zip Y5ik7 parcelfa _2Y9-070' /0 <br /> PROPERTYOwner SdSe f'�Ol./y� Address 2 S -( cn C ity_&a1j�pmakZipff3k2 Phone#Z9f '651-24 tU <br /> Fl.sc Ew.nror.+te _ 3i9_Si•er_r P(a�t V/ 1 )5o-w.sf RSLSZ G AGS Z419 77Z 337 <br /> C•67 Contractor _ _.ddres. City—--- �`-rp _ Lic#_ Phone <br /> Consultant/Sub Contractor S L-� �K�crKu k�w4 Address r��`Z <br /> .7 1Ci ^� /L' Cltypw ,(v, Ll[# u/OL Pnone# <br /> GIS Coordinates X Y Township 3 Sar+L. Range F sectionZ <br /> WORK TO BE PERFORMED <br /> AEW WELL/BORING(CPT GIBE,HYDROPUNCH HARD-AUGER OTHER-) DESTRUCTION(choose type below) <br /> 1g`tOIL BORING# F'P �I g OVER-BORE <br /> -AWELL# [�PRESSURE GROUT <br /> Other <br /> COMMENTS / Gco rtib4t_ (io►r" <br /> TYPE OF WELL INSTALLATION TYPE= CONSTRUCTION SPECIFICATIONS <br /> ITORING - HOLLOW STEM -^� OW OF BORFHOLE !MULTIPLE CASINGj1 <br /> S?0 YES , 0 WELL CASING DIA - <br /> RACTION Q AIR HAMMERRIVEN CASING THICKNESS' TYPE OF CASING Q 5 fL NC OTHER <br /> /D <br /> VAPOR MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED AUGERS OSE <br /> p AIR SPARGE a X'USH POINT GROUT SEAL PUMPED _Yes Ii No (NOTE: MAXIMUM FREE-FALL DEPTH 1S 30') <br /> SOIL BORING p HAND AUGER APPROX BORING DEPTH�_ _ BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> a OTHER. OTHER CONDUCTOR CASING PROPOSED? /a-�(If YES list specifications here} <br /> t�l►er¢IrfS: • eS P—Y= �O r:r.+y 5►S I tr,5 �CTr 7+ti�rc� Lae,e.�L 'fin S^wv(a-a<� <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby aerldT that 1 have prepared this appirenticn and that the wank will be!_r0_Tn Q=Wance with San Joaquin County Ordmanees State Laws and Rates <br /> ants f0egulattnna of the San Joagilln County Hamcwirner or&Ansed agents sigrtat="riirres the Wowtng -1 eerdfy what in the perlreerrtance of the work <br /> for* Ic*fbcs perroftls iissu+ed,I~not arWQy persons stileljeet t4 wuAWERS'COifP+rEIIiSAT9W Lam orCa ifiantla." Car bzftr's t[atag or sub- <br /> oanttaCbng s*rtff M cefffi s the following I o80yy Mat In @re porfarrrtaraae of the work for which this permit is issued.I shall emploYPeasons Subject to <br /> r+roRrcElas CO1ttPFitrSanonrLaws ofCa6rornia- Q <br /> IN�R4+ W1N ADV�NIyI_(ISG_., -�II�Eor111�5,P @ S <br /> >aSrP�C.�TOR�48s <br /> S(grted x Tl!!e/Company <br /> NntNarr,e� a aucan�ttrlbvi•t Date -7-10-00 <br /> DEPARTMENT USE ONLY 1� _C>0 �JY <br /> Appkohen AcoaPted BY Date Issued A,� <br /> Grout Inspection Ey Date Final Inspection By Date <br /> Deamcdon Inspects=By Data <br /> COMMENTS I CONDITIONS <br /> ;UKTING tNtLY AID# <br /> E FEE INFO AMOUNIT REMITTED CHECK a RECD-BY 13ATE PERMIT f SERVICE REQUEST B INVOICE <br /> 2 30 7-+3ee?'332 <br /> 3 I 1/18/2000 <br /> arch <br />