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11/08/99 MON 14:50 FAX 916 858 0605 <br />IT Corpora“on/RC <br /> <br />1?) 002 <br />ORIGINAL <br />WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />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 />San Joaquin County Development Title. Chapter 9-126 3 and thStandards of San Joaquin County Public Health Services. Environmental Health Division <br />e <br />WELL Location MOO fi iardnirtil ililrioss? treet CltY .NAIWte/4- Zip Parcel* c246 -,P to-oe <br />PROPERTY Owner Tor-s_o IA kor_s_TiNG) _Address 152g)LUIS, 4,-,,,..,le yA ec,N),..,,L Zip3521g0 i PhollY 77ki- gq i L) <br />it) <br />C-57 Contractor kli.-1-• Ii41,MATI_Addresst555 6 1-2-cle5t47 City Zip LicalE/29Ph?r‘k (.05E---- 7 g_7 cd <br />ConC!,..Diltant Sub Contractor IT CviceiDeLAddreSS 5 5 plect.cety clgiAtito <br />AruCrir0 <br />P tr4c:# 216E - .3,-S1D <br />GIS Coordinates: X . Y Tow: <br />5:tc.i-ir:) Cie.-I:LA Section Range <br /> <br />UNIT IV <br />WORK TO BE PERFORMED <br />U NEW vvELL / BORING (OPT. GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') <br />ti SOIL BORING # <br />a WELL # <br />'Other: <br />COMMENTS: 'nand/ <br />TYPE OF WELL INSTALLATION riPE <br />El MONITORING a HOLLOW STEM <br />fi EXTRACTION El AIR HAMMER/DRIVEN <br />El VAPOR OMUD ROTARY <br />AIR 5PARGE fl PUSH POINT <br />U SOIL BORING U HAND AUGER <br />13 OTHER. [I OTHER <br />COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br />I hereby certify that I have prepared this application and that then work will be done in accordance with Sari Joaquin County Ordinances, Stale Laws, arid Rule; <br />and Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: "1 certify that In the performance of rho work <br />for which this permit Is Issued, I shell not employ persons subject to WORKERS' COMPENSAtION Laws ol California." Contractor <br />1 <br />'s hiring or sub- <br />contracting signature certifies the following. co ty rformance of the work for which this permit is issued. I shall employ persons subject to <br />WORKERS' COMPENSAT/ON Laws of California. - <br />THE 'A pL1CA Nit MU ST '0 A 1-1-.411,W6Rf<INGIIRS.IN bVAN C E FORALL REQUIREb.INSPECTIONS. <br />Signed x <br />SEE SITE MAP IN UNIT IV WORK PLAN DATED: /2//ic-i?? <br />DEPARTMENT USE ONLY <br /> Date Issued - Area 0 & <br />Final Inspection By <br />)(DESTRUCTION (choose type below) <br />.OVER-BORE <br />U PRESSURE GROUT <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE <br />CASING THICKNESS <br />DEPTH OF GROUT SEAL <br />GROUT SEAL PUMPED: <br />APPROX. BORING DEPTH <br />CONDUCTOR CASING PROPOSED? <br />MULTIF <br />TYP <br />a Yes El No <br />LE CASINGS' YES g NO WELL CASING DIA <br />E OF CASING: El STEEL U PvC El OTHER <br />TREMIE TYPE TO BE USED D AUGERS 01-10SE <br />(NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />o BOLTED TRAFFIC BOX or El STOVE PIPE <br />( if YES, list specifications here)' <br />Application Accepted By <br />Grout frospectiOr% By <br />Destruction Inspedion By <br />COMMENTS / CONDITIONS' <br />Date <br />Date /1 5- <br />ACCOUNTING ONLY: AID* EAU! <br />-r <br />PE CODES FEE INFO AMOUNT REMITTED CHECK I REC'D BY DATE <br />35f)2-- tA1b tz). <br />C-57 LICESSEt) CONTRACTOIVI4USTS1WsrtLICENU*V70