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Dec 14 00 06: 22a C;--is Fisch (20P" 772-3571 r P• 1 <br /> ?TF TECHIvOLGSI_s <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION(PHS-EHD) <br /> 304 E.Weber,Third Floor, Stockton,CA., 95202 CP <br /> (209)468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATF ISSUED <br /> App+-cat'ion K nortoy made Ir San JoaQuin County for a permit to construct ondJor install the work cescnbad. This appllcahon Is made in Oompitance min <br /> Sen Joagu:n County Develop rent Thle,Chapter 9-1115.3 and the Standards of San Joaoum County Public Health Services.Environmental Heattfr Division, <br /> Assessor' <br /> WELL Location 17/5' 2 Nr, r- {fyS�AVS (St• Cro et f1Ut'CT1(OL Gity .K`��Zip —_PBrCeM 1 "2IQ=05 <br /> PROPERTY Owner Cale-�a��a � OT AdIress_����" &,Own _Sbc[ -CityLbr��hZip-90tuphonaY <br /> C-57 Contractor h�nvirNlrlYn ressv��9�5/IrwrL'c5 �/ At� �+• 3iD > cS��3��5 PhoneM 2I9'77 3576 <br /> Consultant Sub Conlractorox!dcrGlrT 01a)�ddessk City—C&a `id Phonel+ <br /> C*zueouif—x <br /> GIS Coordinates X _ Y Township __Rangc_ Section <br /> WORK TO BE PERFQF-MED <br /> NEW WELL I BORING(CPT.GgQPROBE.MYOROF NCH, AND-AUEf,1.01Hg D DESTRUCTION(choose type beaw; <br /> OIL BORING e .5 a l S OVER BORE <br /> O WELL S— O PRESSURE GROUT <br /> 'Other• __ _ <br /> COMIAENTS <br /> TYPE OF WELL INSTAL.I ATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING p HOLLOW STEM DIA OF 80REHOLE 7-in. MULTIPLE CASINGS1 p YES Q NO WELL CASING DIA <br /> O EXTRACTION O AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL O PVC h OTHER. <br /> Q VAPOR Q MUD ROTARY CEPTH OF GROUT SFAS %8-C4-. TREMIE TYPE TO BE USED. a AUGERS OHOSE <br /> O AIR SPARGE O PUSH POINT GROUT SEAL PUTAPEU 0 Yes ONO INCITE:MAXIMUM FREE-FALL DEPTH IS 30) <br /> 1KIL BORING Q NANO AUGE-Ry APPROX...BORING DEPTH !.O '�'�' -O BOLTED TRAFFIC BOX or O STOVE PIPE <br /> O OTHER. �f33THER S�CGT CONDUCTOR CASING PROPOSED,) I if YES list speci!ications here) <br /> COMMENTS: r %# o �•�_���(7/\1X�C.�7 5 O r•C r1 C7�C �i <br /> I�?)__.Olt-rrc�U. .G'"t is r ���tui►=,. t ! - � C�.(�'�—���,. <br /> OTE: OFFSITE 80 NGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> i hereoy obiPy oral'have prepared this 20rl:cation and tral the work will ba done in achord once with San Joaquin COunty Ordinance,,State Laws.and Rules <br /> and Reg ulabors of the San Joaquin County Homeowner Or I'censed agent's signature certifies the following, -I certify that in the performance of the work <br /> for which this permlf is'issued,I shall not omptoy persons subject to WORKERS'COMPENSA TION Laws of California." Contractors hirins or Sub- <br /> canfracrJnq signature certifies t"following .t OBRjry That rn fhe parformanca of the work for wMch Yus permit is issued.t sree emAloy parsons suoieci to <br /> NORKFRS'COMPENSA TION'LawS Of Cah(Orn,e- <br /> THIFAPPLICANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed x �-2 - T tie !S/Li�rl�Q�f- Date <br /> SEE SITE MAP IN UNIT. IV WORK PLAN DATED_ <br /> DEPARTMENT USE ONLY �C� A <br /> Applitat+ors Ac:epted __ <br /> Date issued Grr0 lespechos By —DareF nal inspection ByCate / 0 <br /> OestruciiOn inspection By Oate <br /> COMMENTS 1 CONOITICINS -------- --` <br /> — AFACOACCOUNTING ONLY AIDS PE CODESFEE INFO AMOUNT REMTTED i CHECKOICASH RECEIVETE PERMITISERVICE REQUEST NUMBER INVOICE <br /> 3? 33 CCUaR# oicic?,c4clOu <br /> C-57 LICENSED CONTRACTOR MUST SIGN LICENSE&WORMKYCOMPENSATION DECLARATION <br /> UNIT IV"6/23/99/sign bcpg/MI <br />