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04/28/2000 08:23 <br />DEPARTMENT USE ONLY <br /> Date Issued <br />Date Final Inspection By <br />Date <br />AID# EAC* <br />RECD BY CHECK N AMOUNT REMITTED <br />z <br />Signed Title/Company 'D-4:6:'12- Ivy ityt Pv-r_f-_:_ /14-4,10ezoev, <br />Print Nam Date 7 -/a - e (\UCAA-Ncv-V&in: <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS I CONDITIONS: <br />ACCOUNTING ONLY: <br />PE CODES 1 FEE INFO <br />350 I <br />b 7 6IC <br />ete,C-a'? <br />1 1 rag g <br />ORIGINAL <br />PAGE 3 <br />gfr <br />6(1. <br />(ISCI <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 Courtly Development Title, Chapter 9-1115,3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />Assessor's _ <br />WELL Location 2 3 (0561 5... SaAi-r, Fe Actket Cross Street City Aikr(likn 0- k zip Y•53 7 panzer* .2 Y7 -07 -10 <br />PROPERTY Owner 1O- <br />E <br />O e <br /> m <br />CevAr6.A1° Adress <br />c .,, <br />23(0 - <br />_ <br /> $ fc441 r ' yc t <br />5 <br />ity wetide Ak zip9.5 <br /> <br />-347 Phone# 16/4_ <br /> <br /> iq- 2 <br />Z <br />4 .Y 3 <br />3 ,iq ii z'i Phut ILIer.11 Z(-? 77 -3: <br /> <br />, <br />) <br />. <br />- 4., <br />O-57 Contractor Addres: City . Zip Lio#_ , Phone# <br /> <br />Consultant (Sub Contractor 5 L'EC0Z 1, -,t,tA-,..,.4.1. Address3a0 kilyc.ve.Fak q/A-te. la.' City11,44.144rLicit 49 112 L' phone* ,74, gi..1- Ozioc.) <br />Y • Township 3 45,,,-0-,4 Range q section 2 54., * <br />2094683433 FIFTH FLOOR <br />WELL PERMIT APPLICATION FORM <br />GIS Coordinates: X <br />ci) WORK TO BE PERFORMED <br />EW WELL I BORING ( CPT, GrCEDVE, HYDROPUNCH, HAND-AUGER, OTHER') <br />SOIL BORING # dri) <br />11 WELL # •• <br />0 DESTRUCTION (choose type below) <br />0 OVER-BORE <br />0 PRESSURE GROUT <br />'Other: <br /> <br />COMMENTS: 6rlto <br /> <br />TYPE OF WELL INSTALLATION TYPE <br />MONITORING HOLLOW STEM —7:I.> <br />EXTRACTION 0 AIR HAMMER/DRIVEN <br />a VAPOR MUD ROTARY <br />fl AIR SPARGE tPUSH POINT <br />gSOIL BORING RAND AUGER <br />0 OTHER fl OTHER <br />CONSTRUCTION SPECIFICATIONS <br />DIA, OF BOREHOLE MULTIPLE CASINGS? 0 YES NO WELL CASING DIA:- <br />CASING THICKNESS TYPE OF CASING; 0 STEEL VC fi OTHER: <br />DEPTH OF GROUT SEAL __ TREMIE TYPE TO BE USED: . AUGERS OSE <br />GROUT SEAL PUMPED; Yes n Nn (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />APPROX. BORING DEPTH COLTED TRAFFIC BOX or fi STOVE PIPE <br />CONDUCTOR CASING PROPOSED? it ( if YES, list specifications here) <br /> <br />COMMENTS: <br /> <br />LiS C.ko ck ko a-kr <br /> <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 thc San Joaquin County. Homeowner or lIcenaed agent's signature certifies the following: "/ 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" 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 />WORKERS" COMPENSATION Laws of California" <br />CALLITHEA)NitiViiilt0EtTOR ABANOKKGAliktiN'ADVANCER:IttALLAEOUIREWINOMIONS: