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06/27/2002 12 05 2094683433 FIFTH FLOOR PAGE 04 <br /> 1 <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH <br /> S ENVIRONMENTAL HEALTH DIVISION (i PHSREHDE) <br /> I304 E Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3450 <br /> NON-REFUNnARi W PERMIT EXPIRES 9 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct and/or instal(the work described This application rs made rn compliance with <br /> San Joaquin County Devetopment Title Chapter 9-1115 3 and the Standards of San Joaquin County Public Health Services Environmental Health Division <br /> tcvr4Ty CDVATHOVSE SAN TGAQWN <br /> WELL Location ZZZ W t4 ,Itiy Crass Street rR li T Assessors <br /> SA TVARvtt�i couN . 5 City STOCLO Zip 95_ u7 par eel* <br /> PROPERTY Owner Pok Cltt IES MGMT p PT, Address ItlT I~, SCUTTS AVE, <br /> crty�,fiOC k TSN z+p�y�p 5 phaneft xa9 b 8-33 5} <br /> C 57 ConUactor MITCHELL b t 1( ddress City Ct) jjp gy 61 p 6126 <br /> zip tial 1 Phoned (sib)631-3683 <br /> Con_ sultanl I Sub Contractor ISA M A G-E ENV. address p.Q+ OX $6KK'b'' <br /> Clty U M Lic#_rt p 6 Phone# 9i6)35�-3750 <br /> GIS Coordinates X Y <br /> Township Range section <br /> WORK 70 BE PJrRFORM>:D <br /> 1 NEW WELL I BORING(CPT, GEOPROBE HYDRQPUNCH, HAND-AUGER OTHER") <br /> Q SOIL BORING# Q DESTRUCTION(choose type below) <br /> C3 <br /> 'Other ) 1 WELL# MW- W��. yy_ 11 OVER-BORE <br /> Q PRESSURE GROUT <br /> COMMENTs TNkEF- "- ITE G1'0VN0w1VTF-K MONITORING- WtLL� <br /> TYPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br /> 11 MONITORING 1 HOLLOW STEM DIA OF BOREHOLE-&-FN MULTIPLE CASINGS YES <br /> 0 EXTRACTION Q AIR HAMMEPJDRIVEN CASING THICKNESS 20 4q�TYPE OF CASINGD0 STEEL <br /> ■NO WELL CASING DIA JLIN <br /> VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL G- T ��TREMiE TYP OBE USED VC OTHER <br /> MR SPARGE Q PUSH f POINT 1 AUGERS QHOSE <br /> GROUT SEAL PUMPED (1 Yes A No (NOTE MAXIMUM FREIE-FALL DEPTH 1S 30') <br /> DIL BORING (1 HANDAUGER APPROX BORING DEPT" 25-F T. <br /> I)OTHER 1 BOLTED TRAFFIC BOX or p STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? N 0 (it YES, Inst specifications here) <br /> COMMENTS <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS! <br /> 1 hereby certify that I have prepared this apphcstron and that the work will be done in accordance with San Joaquin County Ordinances -State Laws and Rules <br /> and Regulations of the San Joaquin County Homeowner or licensed agent's signature Certifies the following 1 cerlrly tha <br /> for which this permlf is issued I shall nol employ persons subject to WORKMANt In the performance of the work <br /> 'S COMPENSATION Laws 4f Y t h4 rnla 11 Contractor's erring a sub- <br /> Contraclrng signature Certifies the Following 1 Certtly that rn the perk mance of the work for which this pormil is issued l shall employ persons subject to <br /> WORKMAN S COMPENSATION taws of Cahfiomra " <br /> TH APPLICA T L 48 HRS 1N ADVANCE FOR ALL REQUIRED INS7Zt <br /> Fried x <br /> Tille_ f` Date 0 Z— <br /> SEESITE MAP IN UN IV WORK PLAN. DATED TII6 rot <br /> DEPARTMENT USE ONLY �( 7 / <br /> IpplicafiontIA5PAccepted By _ Date Issued [J!, Areal/ <br /> Grout Inspection By Date Final Inspection By Date T <br /> estruaion Inspection By Dale <br /> OMMENTS 1 CONDITIONS <br /> ACCOUNTING ONLY AID# FACS <br /> ODES FEE INFO AM N7 REMITTED CHECK#!CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> �� <br /> &A-7 100033 <br /> JIVIT TV-6/1/99 !sign bkpg/Mi <br />