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06/20/2000 09:52 2094683433 FIFTH FLOOR PAGE 02 <br />WELL PERMIT APPLICATION FORNf UNIT IV <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICIMECEJ \J� <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD <br />304 E. Weber, Third Floor, Stockton, CA., 95202 JUN 2 8 2000 <br />(209) 468-3449 ENVIRONMENT HEALTH <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT/SERVICES <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 San <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />I :l `I �G G Acs ni�, '�� —city l } �p� Assessor <br />WELL Location rwc Cross Street (� CI � �'C�1�C 61 �O�e� Parcel# (1 i `-IC) - Oa. <br />PROPERTY Owner 1J�1\�ieY�c �� -11� Address �C I i LCC��cL r��E _ City ��C C���W rpCj-honeM <br />C-57 Con—Address r� (i �C�GlYV15 �t0. City v��Bu�Zlp tfj i/ZicA�45`Id�honeit 1 i0 /'(��O%�o <br />Consuttant / Sub Contractor ppAdd�ress,OG (�r�\�fe A°' e Gtry cvuw e- Lica Phone# �1I-(C3 S -"f rJQZ1 <br />�Gi 2,•..f.l r`3aC�h .S S�ti. t , � <br />GIS Coordinates: X Y Township Range Section <br />WORK TO BE PERFORMED: <br />17,/NEW WELL / BORING ( CPT, GEOPRO85,-HYDROPUN HAND -AUGER, OTHER-) 0 DESTRUCTION (choose type below) / <br />-JY501L BORING # i', a OVER-80RE <br />j WELL # 0 PRESSURE GROUT (� <br />'Other: �? <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />D MONITORING D HOLLOW STEM DIA. OF BOREHOLE ; 1" MULTIPLE CASINGS? 0 YES �/ NO WELL CASING DIA <br />n EXTRACTION p AIR HAMMERIORIVEN CASING THICKNESS N TYPE OF CASING VSTEEL D PVC O OTHER: <br />D VAPOR D MUD ROTARY DEPTH OF GROUT SEAL N 4 TREMIE TYPE TO BE USED: D AUGERS BHOSE <br />o AIR SPARGE 96USH POINT GROUT SEAL PUMPED: p Yes WNo (NOTE: MAXIMUM FREE -FALL DEPTH IS 301) <br />D} -SOIL BORING 0 HANG AUGER APPROX. SORING DEPTH D BOLTED TRAFFIC BOX or D STOVE PIPE U <br />0 OTHER: D OTHER CONDUCTOR CASING PROPOSED? n.JR (if YES, list specifications here). n <br />COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS �) <br />1 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 Rulss v <br />and Regulations of the San Joaquin County. Homeowner or licensed agent's signature certtfles the following: '7 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 Ca/ifomia." Contractor's hiring or sub- <br />contracting signature certifles the following: "I certify thal In ft performance of the work for which this permit is issued, 1 Shall employ persons subject to <br />WORKERS' COMPENSATION Laws of California." <br />" CALL THE UNIT IV INSPECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS <br />1 <br />Signed x Tide/Company. (1V�1iJ <br />Print Name L �. (1y Date �O/ ";l'7 Inc) <br />SITE FILE ADDRESSlWORK PLAN DATE: S -- i �� ,ao� <br />DEPARTMENT USE ONLY �1 Com_ <br />Application Accepted 8y Date Issued Areae? <br />Grout Inspection By Date Final Inspection By Oate <br />Destruction Inspection 8 �_F L' " Date _ 0 L c <br />COMMENTS / CONDITIONS: i,J 4 t�: C - 'f ` `{• J,' " <br />ACCOUNTING ONLY: AID# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK #REC'D BY DATE PERMIT EQUEST N INVOICE <br />3sz�r �y y— ��3iy CJ �/� O <br />C-57 exp. WC/waiver_ C-57 Letter of Authorization to sign permit ncroachment doa(s)�' 5/17/00 <br />