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UNIT N <br /> ppLICATION FtW\ <br /> WELL PERMIT A S RECEVED <br /> COUNTY PUBLIC HEAL T PH EHD") NOV 2 8 2000 <br /> SAN JOAGZUIN CA., 95202 <br /> ENVIRONMENTAL HEALoTHS lockfon ENVIRONMENT HEALTH <br /> Weber, Third PIo EN <br /> 304 E. (209) 468-3450 PERMIT/SERVICES <br /> FROM DATE ISSUED <br /> application is made in compliance with <br /> NONREFUNDABLE PERMIT EXPIRES 1 YEA This app Environmental Health Division. <br /> Joaquin County Public Health SeNices, Assessor's <br /> uin County for a permit the Standards of!San Joaghe work describe . <br /> made to San Joaq $S D0�.T0 K 1;LQZ, Parcel# <br /> Application is hereby Z <br /> uin County Development Title,ChOaptsr >>15 3 an SAN TO A Qd114City 2p9-46$- 3S� <br /> San JO aq CGVNv( GO 1pati V Cross Street 0 Zip9,0 Phone# <br /> xt2 ERS wEl3�o KT c0t[S �`� city-U0191 <br /> WELL location SA N �A 1\QU 1 Address 1 12 5 vA t.LIrY G Phone# �' <br /> Q I tl fr Z,p Z Lic#b 2 0 <br /> PROPERTY Owner AGl1.I'C 399 S ki E P 1A0 CI1y RAW" phone# 9tt. "32 <br /> 15 G N tyV. Address O $6 9 City 11 1 e T Lic# s$ <br /> 5_19— <br /> C_57 Contractor p,O X Section <br /> (k A(�It G� NV• Address Range <br /> Gonsn t 1 Sub Contractor Tflwnship <br /> Y <br /> n DESTRUCTION(choose type below) <br /> DESTR <br /> GIS Coordinates:X OVER-BORE <br /> WORK TO BE PERFORMED PRESSURE GROUT <br /> !BORING(CPT GEOPR RENG#D 10'L NCH,HAND AUGER,OTHER') <br /> NEW WELLSOIL BO <br /> 4 WELL# <br /> 'Other: YES NO WELL CASING DIAN1� <br /> CONSTRUCTION SP `µATI MULTIPLE CASINGS? PVC a p7HER: <br /> COMMENTS- CONSTRUCTION TYPE STEEL O <br /> TYPEf DIA.OF BOREHOLE�r TYPE OF CASING: AUGERS <br /> �� <br /> d MONITORING HOLLOW STEM <br /> AIR HAMMERlDR1VEN CASING THICKNESS T,1�� TREMIE TYPE TO 8E USED: <br /> EXTRACTION 11 DEPTH OF GROUT SEAL Yes No (NOTE: MAXIMUM FREE X Ao LQ S OVE P <br /> 0 0 MUD ROTARY F T n BOLTED TRAFFIC <br /> U VAPOR PUSH POINT GROUT SEAL PUMPED: D 5 <br /> t)AIR SPARGE APPROX.BORING DEPTH 0 (if YES,list specifications here): <br /> 4 HAND AUGER <br /> SOIL BORING CONDUCTOR CASING PROPOSED �14_ S wort L <br /> BOTHER: apR4 E AG-E v_NvIRO�M -N + <br /> 0 E o� WO t� DE.TAILEU IK RAN <br /> COMMENTS: -3 P V T��%< I 10 a o <br /> SE E ACCESS OR ENCROACHMENoTdPERMITS!tLaw <br /> OFFfl <br /> SITE BORINGS REQ w+Ih San Joaquin tfiat in the performance <br /> NOTE: !certify <br /> besignature certifies the following: " <br /> d this application and that the work wilt be done in actor a arsons s <br /> l hereby certify that I have prepare,un County. Homeowner or licensed agent'sCOMFENSATlON taws of California."I sallen' Contractor's f <br /> and Regulations of the San Joaqpersons subject to WORKMAN'S <br /> 1 shall not employ p �r ane work for which this permit is issued, !shall employ P • <br /> for which this permit is issuedNS- <br /> , ! er ily that in the Pe'fo 'an`e <br /> contracting sign oMpENSATION laws of Califomia." `a <br /> Co ALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIO <br /> WOt�KMANS THE APPLICANT MUST C Date <br /> Title <br /> f�L`( t <br /> Signedx WORK PLAN. DATED 1000 <br /> SEE SITE MAP IN UNIT 1V <br /> DEPARTMENT USE ONLYY 0 '�/ `� 1 <br /> Date Issued <br /> p� Final Inspection By <br /> Application Accepted By Date <br /> Grout Inspection By Date <br /> Destruction Inspection By <br /> COMMENTS 1 CONOITIONS: FAC# <br /> AID# DATE PERMITISERVICE REQUf <br /> ACCOUNTING ONLY: 1CASH RECEIVED BY <br /> PE CODES FEE INFO AMOUNT REMITTED Cl 0 4 <br /> 3S0( r9 ` � k <br /> UNIT TV-6/1/99/sign bkpg/MI <br />