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CHECK N <br />oz 22--T <br />FAcUt <br />REVD EY <br />Cz <br />DATE <br />7-1.3 <br />SERVICE REQUEST ft \NVOICE <br />1/18/2000 <br />ACCOUNTING ONLY: AlDit <br />-35D <br />PE CODES FEE INFO AMOUNT RENIITTED <br />Application Accepted By_ <br />Grout Inspection By Date Final Inspection By <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />DEPARTMENT USE ONLY <br /> Date Issued 7- -00 Area b6) <br /> 0/ <br />sii# 602-33? <br />84/28/2000 @8:23 2094683433 FIFTH FLOOR R I P6E11\re <br /> <br />WELL PERMIT APPLICATION FORM <br /> UNIT IV <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 9-1115,3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />Assessor's <br />wELL Loc.3tion Z.-15‘,q 5, C..k i:c Cross Street City iZsuett Br4t.1K. zip ?53€a? Parcel r 2zi 070 - 0 I L <br />PROPERTY Owner 1),-, rIA - Address..L O'Carrei S trret 1$10 <br />.'i e c>s <br />city San FraAcz,c, Zip */09 P:Ihoonnete:75 26:`:: <br />1-7 i3ch 3'19 Ske v • 5Pit 95 2.5 Z GO 3 <br />C-67 Contractor Address City" Zip Licit e, <br />Consultant Sub Contractor '-)ECDR- Address 30i1 Kl9ove V.A- 5,11-r ILA-, (0102_ <br />GIS Coordinates: X Y Township 3St"-, Range EAS..11- Section Z 11 <br />WORK TO BE PERFORMED <br />[(NEW WELL/ BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') <br />escaL BORING # _ - Z_ 3 <br />Ei NELL # <br />'Other Fi sck Lilt 6-e- , 6 p - a, G e <br />COMMENTS: <br /> <br />TYPE OF WELL INSTALLATION TYPE <br /> <br />MONITORING HOLLOW STEM <br /> <br />a EXTRACTION AIR HAMMER/DRIVEN <br /> <br />fl VAPOR UMUDROTARY <br /> <br />BAIR SPARGE )(PUSH POINT <br /> <br />SOIL BORING LI HAND AUGER <br /> <br />THER! n OTHER <br />CONSTRUCTION SPECIFICATIONS <br />DIA, OF BOREHOLE MULTIPLE CASINGS? a YES II/NO WELL CASING DIA; <br />CASING THICKNESS ',,,.. , - TYPE OF CASING; I] STEEL A 1VC ))1 OTHER: <br />DEPTH OF GROUT SEAL ,, . TREMIE TYPE TO BE USED: alAUGERS [NOSE <br />GROUT SEAL PUMPED: D Yes (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />APPROX. BORING DEPTH W a BOLTED TRAFFIC BOX or I] STOVE PIPE <br />CONDUCTOR CASING PROPOSED? (If YES, list specifications here): <br />&P -a, GP av:tk.G01 .6 /5 reeJ Grtek <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 Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: "1 certify that in the performance of the work <br />for which this pennit Is issued, I shell not employ persons supject to WORKERS' COMPENSATION Laws of California." Contractors hiring or sub- <br />contracting signature certifies the following: 1 certify that In the performance of the work for which this permit ;s issued. I shall employ persons subject to <br />woRKERS' COMPENSATION Laws of California." <br />CA44170001Mr1014tOtOtOR..:405KOSOLGtfiRaiN'ADVANCEIPO:RALLIREQUi REDA TE-t-MOW . •. <br />Title/Company 5 Z(--017- -At.' 04A <br />Attouje.v. Data 7-IC - <br />ON <br />I <br />ORIGINAL <br />a DESTRUCTION (choose type below) <br />OVER-BORE <br />fl PRESSURE GROUT <br />Phone#% &;/-0'/D&) <br />COMMENTS: <br />Signed <br />Print Name ICA au c...kVe.,