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MONITORING <br />XEXTRACTIO <br />XVAPOR <br />XAIR SPARGE <br />fl SOIL BORING <br />XOTHER: <br />2-10-2000 11:24AM FROM <br /> P 1 <br />PAYMENT <br />RECEIVED WELL PERMIT APPLICATION FORM UNIT IV <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />\NELL Location g s, \ 0 A-Vollt.02, Cross Street Zip fsao6 F=res cit. Stock/Do <br />PROPERTY Owner F10,...y GI 8 an\ e-,,S- Address 971/q Paitak) Vail, ''tY- S+ Zip 7,5R0 Phone# (Y9)16236 <br />C-57 Contractor tti it ri il.' F---AVt Address i0OLLiti ICIVO (A1Xy City koal-ciV Cc' f Lic#121_41j_Phone# 0/ 6)&3 I -3373 3 <br />Consultant / Sub Contractor Clear-v.40c G-ro I AddressItko- I I <br />1 Q -7- <br />et-E <br />e. j <br />L5 Da 4 Phon1/ ..Z' Pi-, Rkk ,) " IlY <br />ii0 0)-30-t-QM3 <br />9...kt- — A iJeorngA,, -li <br />Section <br />WORK TO BE PERFORMED <br />XNEW WELL I BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />El SOIL BORING # <br />D- )(WELL #QP1F1* s4- -SFr— <br />U DESTRUCTION (choose type below) <br />OVER-BORE <br />p PRESSURE GROUT <br /> <br />'Other; <br /> <br />D ,..a--04-(.2- ekto-c -,yrv..-1,-K, e- *Ira 1-4,-i. -s-0; i Aker- ex- kecii,,A <br />TYPE OF WELL 615,4)...t INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS . <br />DIA. OF BOREHOLE 10 . /MULTIPLE CASINGS? 0 YES NO WELL CASING <br />CASING THICKNESS Sisail-JelaikTY, IPS OF CASING: U STEEL )(PVC 0 OTHER: <br />DEPTH OF GROUT SEAL .-Se;,_ cLitaickiet TREMIE TYPE TO BE USED: 11 AUGERS OHOSE <br />GROUT SEAL PUMPED: G Yes El No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />APPROX. BORING DEPTH 30 f-± ils--f-i )(BOLTED TRAFFIC BOX or a STOVE PIPE <br />CONDUCTOR CASING PROPOSED? 00 ( if YES, list specifications here): <br />COMMENTS:. <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS _ <br />I 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 ReguiatiOnS of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: "i <br />Certify that in the performance of the work <br />for which this permit is issued, I shall not employ persons subject to WORKERS' COMPENSATION Laws of California." <br />Contractor's hiring or sub- <br />contracting signature certifies the following: I certify that in the performance of the work for which this permit is issued. I shall employ persons subject to <br />VVORKERS COMPENSATION Laws of California." <br /> <br />CALL TILI .urirriv INSPECTOR 48 WORKING HRS IN ADVANCE FOR REQUIRED INSPECTIONS. . . <br />Signed x S.----)2- )-2--------- TrtteCompany Pi-D.:f.4 Ciear-victfer 64040 _ <br />Print Name A dame) R, Ale..-luMart Date <br />P-,:"..V.t.g:-:41::::-.L.,:j/Cit • Mid .735- ..':',_' - ......,...,....:,...,. ...._......,....„-.-„,—.....-, <br />6 1 <br />Application Accepted By <br />Grout Inspection By_ Date Final inspection By <br />Date Destrucn Inspection By <br />COMMENTS / CONDITIONS: <br />j4,Q_y o 12001 • <br />SAN Ja'Abuirtim T-y <br />PUBLIC HEALIH Sr ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />ENVIRONMENTAL HEALTH DI KYI: 304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <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 application is made in compliance with <br />JoaquinSan <br />County Development Title. Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />GIS Coordinates: X • Y Township Range <br />COMMENTS: <br />Ve_ <br />KHOLLOW STEM <br />El AIR HAMMER/DRIVEN <br />13 MUD ROTARY <br />13 PUSH POINT <br />HAND AUGER <br />OTHER <br />DEPARTMENT USE ONLY <br />Date Issued Area <br />Date <br />FEE INFO <br />ACCOUNTING ONLY: <br />PE CODES <br />AID# <br />AMOUNT REMITTED <br />(oo <br />FAC# <br />\i <br /> REC'D BY DATE CHECK* <br />P.0 ICS k 0l <br />PERMIT / SERVICE REQUEST # INVOICE <br />„Ul# <br /> (42 / 9 7