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Y <br /> UNIT IV <br /> WELL PERMIT APPLICATION FORM <br /> SAN JOAQUIN COUNTYLIC HEALTH SERVICES <br /> ENVIRONMENTAL LIVB � " <br /> 304 E. Weber, it r Stockton, CA., 95202 <br /> 2468-3450 <br /> ON-REFUNli PER[t1T EXPIRES T YEAR iiiROM 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 /> ELL Location 50100 A UA I S C WAY Cross Street ill DIXON City TOCk TOM Zip 5 Parcel# <br /> PROPERTY Owner STOCt1 14_MtT90 &IRPOPT,\ddress__�OOC_5�A18f.��Wpity Ti Zip_2jL06 Rhone# "T, 1a '°� <br /> 5 Contractor 111 LL 01 a Addreas t 1 M L ` City 1 A I Ci ip 5 U # 2. 1'" Phoned 11�� 1 <br /> ECS t.=Iii <br /> Consultant t Sub Contractor so <br /> F ` {� w Address e - City � N C It U0t S ,�Phone#jt ` " . <br /> MVAI I` <br /> GEIS Crrordinates:X Y Township Raise Section <br /> WORK TO SE PERFORMED <br /> NEW WELL/1 BORING(CPT,G OPROSE,HYDROPUNCH,HAND-AUGER,OTHER-) 11 DESTRUCTION N(choose type below) <br /> WEL <br /> OVER-SORE <br /> tI Ft1NLa PRESSURE GRO T <br /> SELL# Int -1 �dHI <br /> *Other; <br /> COMMENTS: <br /> TYPE OF WELL CONSTRUCTION"PYRE CONSTRUCTION SPECIFICATIONS <br /> MONITORING H L.LOW STEM DIA.OF 130R HOLE " N MULTIPLE CASINGS?11 YES S NO WELL CASING DIA: <br /> [1 <br /> EXTRACTION AIR HA MERIDRIVEN CASING TLII KNESS C t4 TYPE OF CASING: STEEL #PVC a OTHER,- <br /> gVAPORHSBC?ROTARY DEPTH OF GROUT SEAL VF TREMIE TYPE TO BE USED. IT AUGERS &HOSE <br /> AIR..SPARGE PUSH POINT GROUT SEAL PUMPED: f Yds a No (NOTE: MAXIMUM FREE-FALL DEPTH TH I S 3 ' <br /> SOIL.BORING a HAND AUGER APPROX.SOLING DEPTH__ ' T BOLTED TRAFFIC BOX or a STOVE PIPE <br /> OTHER: CONDUCTOR CASING PROPO SED (if YES,list specifications here): <br /> COMMENTS <br /> TPERMITS! <br /> [heretay certify thdt I Dave prepared Ibis apiicatian end that the�rork gill e dine i acordan �+rit Stirs Joaquin Cotan€y Trdinnces,State Lavv .and Pastes <br /> inti Realations of the San Joagirs Caunty: I�ornecirner or licensed agent's signature rtifies the follov�in : >,I orYi1"y of ita telae Perl`�ar arsoe df tea r6r <br /> for" fsicPs tfsix laerrrrit is i ,ssaecf;l sFta16 rice'&easalo �Serta scrta�ed #o CJRIPI'S CGftIFaEAfSI'll1T'dC,11 f�as f Caitorrsla.' Contras#car`s hiring or scab- <br /> ;otractirg igna6tare certifies the fdllo�ving: '!�er7th;That irz ftp perfearr:ace of the avcark,for hidh ihi�larraTi2 is issct,1 shalt rrt; lra,1°��tCart s+a5�act 1 <br /> t/✓C)Rd{�a9R COPEISt 7`dtlsf G.au�s cal �feloraa.'" <br /> & L ICSIRS IN ADVANCEALL EQUIRED IIS 'TI <br /> Signed x itle <br /> 001, { Date <br /> SEE SITE MAP IN NIT WORK PLAN. <br /> DEPARTMENT USE ONLY <br /> Application Accepted Ey Date Issued A a <br /> Grout Inspection ay Gate Final Inspecticsn y <br /> Destruction Inspection Ey Date <br /> COMMENTS l CONDITIONS: <br /> FAC# <br /> ACCOUNTING ONLY: AID <br /> INVOICE <br /> E CODES FEE INFO AMOUNT R MITEO CHCK#1OA FRECEIVEDY DATE PER ITISE ICE REOLIEST NUMBER <br /> 31-01 . <br /> 00 <br /> I sMTT TV«ArsIdo 1,6nr€b1i <br />