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EST # INVOICE ACCOUNTING ONLY: ONLY: AID# FAC# ()C-' (-7 EncraGcbment doc_(s),_ 5/17/00 AMOUNT REMITTED CHECK # REC'D BY DATE 9t -4' C-57 exp WC/waiver C-57 Letter of Authorization to sign permit FEE INFO PE CODES 06/20/2000 09:52 2094663433 it- I r Luu. WELL ...ERMIT APPLICATION FOF. SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION (PHS-EHD 304 E. Weber, Third Floor, Stockton, CA., 95202 (209)468.3449 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in cornolgregAilittie (.4 Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services. Environmental Health Division. ICAsk W•fv\e111&3C..i kle Cross Street Section GIS Coordinates: X WORK TO BE PERFORMED: 3/INEYV WELL / BORING ( CPT, GEOPRO8E.ROPUNC HAND-AUGER, OTHER') 1:1 DESTRUCTION (choose type below) E-OIL BORING # ovER-80RE U WELL # a PRESSURE GROUT *Other: COMMENTS: la/SOIL BORING 0 HAND AUGER TYPE OF WELL INSTALLATION TYPE fl EXTRACTION U AIR HAMMER/DRIVEN U OTHER: fl OTHER MONITORING Q HOLLOW STEM AIR SPARGE 41PUSH POINT VAPOR U MUD ROTARY CONDUCTOR CASING PROPOSED? Or (it YES, list specifications here). CONSTRUCTION SPECIFICATIONS DIA. OF BOREHOLE a " MULTIPLE CASINGS? LI YES 60 WELL CASING DIA: Al Pc CASING THICKNESS x) P TYPE Or CASING IfSTEEL a PVC a OTHER: DEPTH OF GROUT SEAL Ar A TP,EMIE TYPE TO BE USED: Q AUGERS OHOSE GROUT SEAL PUMPED: U Yips FilVo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') APPROX. BORING DEPTI-1215T1 I b91„ BOLTED TRAFFIC BOX or STOVE PIPE commEN-rs: S 0142_ In e_- (1,A 1CC.),-.: -. .4-il)(i s;\ :".(' ' "1r . ) ( ql 'A ,. ,4- Ti-iT OckL.-1., '1-1 CL,_,.. NOTE: OFFSITEtORINGS REQUIRE ACCE 5 OR ENCROACHMENT PERMITS .Crpe lc...PS I hereby certify that I have prepared this application and that the work will be clone in accordance with Sari Joaquin County Ordinances. State Laws, and Rules 12, and Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ persons subject to WORKERS' COMPENSA770N Laws of California." Contractor s hiring or sub- 1 ,:k - contracting signature certifies the following: 1 certify that In the performance of the work for which this permit is issued. I shall employ persons subject to WORKERS' COMPENSATION Laws of California.' * CALL THE UNIT IV INSPECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS Tille/Company T . Date \ al a--1 1 on EEO* tik Date Issued Area CA (-CZ_ Final Inspection By Date ENVIRONMENT HEALTH - PER 4 M_51\VED JAN 0 4 2001 UNIT 1V ENVIRONMENTAL SCIENCE ASSOCIATES JAN 0 3 2001 WELL Location PROPERTY Owner Utn.S\IQ.,(5..t c)-•••\ Ci -c —ge,Ci Address -5 0 I PaCk'cl-K_ Age_ • city -t-Octik.0 0 Zipq5-a0 a.Phone# .S...Z TeX, Address 0,110 46‘.01/1,C /414 e.. • City tCHicl ZIPI t•I'77t_ict$1053,47phone# (510)5 (08 - '1(407k) C-57 Contractor V 4.0 el.e_A O Consultant / Sub Contractor EY1\r.*(01-e,v‘iikl Address lOtt WIN trs 6 City tr.Cyctr‘tepiti.ic# Mi.) e.I30 , Y , Township Assessor's or,/ fita.61Crl zio q594 1 .D. parcel# 115 - Range Phoned 010) 6.,11 -14500 , 1 ) °c) Signed x etE\ Print Name C, AS.k6.1 eys --st\rk_ .. _ - \\-1 I 60 Application Accepted By Grout Inspection By te Destruction Inspection By Date COMMENTS / CONDMONS: SITE FILE ADDRESS/WORK PLAN DATE: DEPARTMENT USE ONLY <11-0 r 1^,