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1 1--22-1 9919 :,1 1 Pt:1 FROM P- 2 <br /> i <br /> WELL PERMIT APPLICATIO14 FOR-UM Uill"` IV <br /> r � <br /> SAN JOAQUIN COUNTY PUBLIC HE LTH SERJ, c ..'�� <br /> ENVIRONMENTAL HEALTH DIVISION 1PHS-E.1-0 VIED <br /> t J <br /> 304 E. Weber, Third Floor, Stockton, CA., 95?C►l NOV24 1999 <br /> (209) 488-3449 L_NV!R0iV N1E_zNTi�L H <br /> Pc EALTH <br /> NON-REFUNDABLE PERMIT F-XPIRES 1 YEAR FROM DATE t$3uED ' RA/ir T I `SERV'ICES <br /> Application is hereby made to San Joaquin County for a parmit to Constrict and/or install the work deachbed. This application is made in compliance with <br /> San Joaquin County Development <br /> /'Title, Chapter 9.1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> U-2,4 f� P4-- '-- Sfi?S�Or'g <br /> WELL Location � t/) 5 Cross Street City Zip Parrak3 'I <br /> PROPERTY Owner ' T�� Andress . � City'L Ziyt Q Phozz»g2J <br /> '/� `�l�i5catdfi' / <br /> C-b7 Contracfor�lf ���KCI l� Address /"� •„City <br /> Consul•.a»t/Sub Cantraeto ►n, Address C Lis . <br /> dy <br /> :sIS Coordinates:X Y .Township ^ 4 RangefkiE -tion <br /> SeZS <br /> ''^RK TO 8E PERFORWED - <br /> NE:M WELL/SORING(CPT, GE0PR0BE. HY0ROPUfdCH,HAND-AUGER,OTHQ DES T RUC`ION'(chooee type belo%0 <br /> 0 SOIL BORING# L nv&R-nORE <br /> WELL# -rwo "iF^ESSURE GROAT <br /> -Other- <br /> COMMENTS' <br /> rYPE OF WELLS INSTALLATION TYPE COMSTRUCTION SPECIFICATIONS <br /> );�MOWTORING HOLLOW STEM DIA. OF BOREHOLE MULTIPLE CASINGS:)(YES C 1':0 lJ LL CASING DIAD <br /> j EY,TRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS ()TYPE OF CASING. XS T EEL ;(7`JC Q OTHER: <br /> n VAPOR -R%1UD ROTARY DEPTH OF GROUT SEAL TREAIE i'/PE TO 3_i_!SiED' tj AUGERS GHCSE <br /> �,AIR SPARGE. Q PUSH POINT GROUT SEAL PUMPED: 0 Yes Q No (NOTE: Mo-V-17PA_M F%!_E-LA1.-i_ DEPTH IS 30' <br /> Q SOIL BORING Q HAND AUGER APPROX. BORING DEPTH G P_L7ED TRAFFIC LTOX or Q STOVE PIPE <br /> 0 OTHER. Q OTHER CONDUCTOR CASING PROPOSED?dam_(if YES.list specK,—tiors hore;: <br /> ,Q MENTS: / kn <br /> - <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACFH1ifiENPE NMTS <br /> hereby certify that I have prepared this application 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 cartifiss the following: "f certify that'rn the par ormance of the <br /> .%r which'his permit is issued, f shall not employ persons subject to WORKERS'C0f11PEAISRTI©At Laws of Cslifcmia." Contractor's hirino or sub- <br /> ,�_-ntracting signature certifies the fol owing "I certify that in iho performance of the work for which this pgrmif i;;issutto. 1 sne!;employ persons subfact to <br /> 1ORK.ERS'CO3VPENSA71ON Lairs of California." <br /> T1iE APPLICANT MUST:CA-tL 4l3'�h R, L REEXUIRED!MSPECTIONS. <br /> Signed x i1pd i Tdle tjzz ev- Date �3 <br /> T M� IN UNIT 1%..1 1111 ORIS I LA.� DAT : �( o <br /> // DEPARTMENT USE ONLY <br /> .'application Accented 6Y - i ` , ,_V It Dale Issued Xfv q CL>'1Area L l ) <br /> Grout Inspection By tate 2 Final inspection 8v ✓% ;ale I Z G v G <br /> jastructlon Inspection B, C2te <br /> COMMENTS/CONDITIONS: V ~ <br /> ACCOUNTING ONLY- I AID# <br /> •� PE CODES FEE INFO I AMOUNT RErWTTED CHECK# R C' ;SV DATE PERMIT I SERVICE REQUEST t INVOICE <br /> i <br /> jj <br /> C-577 L'ICE,NSED.CQN'r?- .CTOR;NITSST SIGN 1_1 ' S • �1�T��S'G��`r�'�N511:dI! nECLAPLATIOT1 <br /> LI NIT IV- 6/23/99 /sign bkpo/MI <br />