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1-14-2000 2 47PM FROM - - P 3 <br />WELL PERMIT APPLICATION FORM 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_Y YEAR FROM DATg ISSUED <br />AppllcaJori is hereby made to San Joaquin County for a permit to construct and/or install the work described Th a application is made m compliance ws h <br />San Joaquin County Developmail Title Chaptee 9-1115 3 and the Standards of San Joaquin Couri'y Public Health Services Environmental Health Dmsioz <br />Assessor's <br />WELL Location La or. Cress street <br />5'-GC v(: Cry Lfla Zip Parcel# 4 <br />Vra>1 Address 1 �• 'K 6(50J C,, , n.wvv TIpR��3PhoriE#12S $q2-SC4s_ <br />PROPERTY Owner s�� j i k _ �j 1 } <br />G57contractor 'riw j/P ll_111_►��`GGh�l •-Addrelss �.�. City1�C�i rsp�¢ ltidf���Ohone#x'7^�-�tS <br />Consultant 15ub Gantra-tor�C- 114 .y.►'Address 31L� cl+� Q' City Lcsy27D'7�� Phase# «' d31 <br />GIS Coordinates X . Y <br />WORK TO BE PERFORMED <br />NEW WELL / BORING (OPT GEOPROBE, HYDROPUNCH, HAND -AUGER OTHER`) a DESTRUCTION (choose type below) <br />0 OVER -BORE <br />(j SOIL BO211-111- <br />ING # <br />[] WELL , W - -1W ' Ij PRESSURE GROJT <br />*Other <br />COMMENTS A, V%� <br />TYPE 2E WELL INSTALL ATION TYPE CONSTft1UCTI0 P1:CIFICATIONS <br />XAONITORING HOLLOW STEM DIA 0= BOREHOLE y MULTIPLE CASINGS? U YES ,6*40 WELL CASING CIA � rl <br />0 EXTRACTION 0 AIR HAMMENDiRIVEN CASING THICKNESSS 0 TYPE OF CASING 13 STEEL PVC a OTHER <br />0 VAPOR a MUD ROTARY DEPTH OF GROUT SEAL --5-1 TREMIE TYPE TC BE USED ZS:AUGERS aH0SEE <br />U <br />AIR SPARGE Q PUSH PAINT GROUT SIAL PUMPED %Yes ONO (NOTE' MAXIMUM FREE -FALL DEPTH IS 30') <br />•Q SOIL BORING a HAND AUGER APPROX BORING DEPTH, � S r , _OLD TRAFFIC BOX or jj STOVE PIPE <br />B OTHER _0 OTHER CONDUCTOR CASING PROPOSED?—(If YES list specimatsons here) <br />Township Range Section <br />COMMENTS <br />NOTE- OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br />1 hereby certify that i have orepared thm application and mat the work will be done in accordance with San Joaquin County Ord:nenoas, State Laws, and Ru es <br />and Regulations of thern <br />San Joaquin County Noeowner or uceised agent s signature cert ies the following "i certify that in the performance of the work <br />for which this permit is issued, I shall not employ persons subject to WORKERS' COMPSKSATION Laws of California " Contractor's hiring or sub <br />contrecting aigns'ure certifies the following "i Cerrfy tFat in the performance of the work for which this pefmft Is issued i shal employ persons subject to <br />W RXERS' COMPENSAVON Laws of C011(cmia " <br />TH PP IT MUST CALL 46WORKING,HRSIN, ADVANCE FORAL4i gQ0IRtE) INSPECTION$ <br />c4'I_-7_2600 <br />S shed Tstle�,� - --Date <br />SEE SITE MAP IN UNIT IV WORK PLAN DATED' <br />/ ],J DEPARTMENT USE ONLY 1 <br />AppllcaJon Accep`ed By f-4 lig Date Issued Ill y oD AreaL�� <br />Grout Inspection By <br />Date Finsl inspection 6y OatA �— <br />Date _ <br />COMMENTS i CONDITIONS <br />ACCOUNTING ONLY AID# <br />PE�r_7FEE INFO AMOUNT REMITTED CHECK # <br />- on 0e, In C4 `i (. <br />.C_$�FJNSED CONn <br />UNIT Til .6Y23/99 /sign bkpg/MI <br />REC'D BY DATE <br />PERMIT I SERVICE REQUEST # 1 INVOICE <br />"L_ 11101 <br />DECLARATION <br />