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COPY <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 YEAR FROM DATE ISSUED <br /> Application is h by made to San Joaquin County for a permit to construct and/Qr install the work described. This application is made in compliance with <br /> San Joaquin unty Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br /> Bo' ,Jor-po eF c� 4 11'y 51<zdef' �.l Assessor's <br /> WELL Loc tion y3or t>ec_; of Ingres rr�:on of R.¢. Cross Street (1or/al No11au pd City —r✓a Ga Zip s3�6 Parcel# <br /> PROPERTY Owner Pom bn rt_aI h Address IZSS— C.J. ll 5}. CityT 44::5 Zip 1 '3246 Phone#)2oY)83S r1Yy1 <br /> C•67 Contractor !'Iec�sj'oA SuMo)�IV,/ftAddress 1`400 5. 5-62- Si-. cityR0 i #�n � Phone# S7oJ2a7yS3S^ <br /> 12 n, L 9,180`! <br /> Consultant/Sub Contractor Address 2101 CJe bS1tnl 5.1 City Qa, and Lic* Phone# 1�1 6L3-9/Qo <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> XN`E-Y�L I 10ORIN (CPT,GEOPROBE,HYDROPUNCH. ND-AUGER.OTHER-) []DESTRUCTION(choose type below) <br /> SOIL BORING# GMx' Q OVER-BORE <br /> []WELL# []PRESSURE GROUT <br /> 'Other- <br /> COMMENTS: <br /> OtherCOMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> []MONITORING []HOLLOW STEM DIA.OF BOREHOLE 05A 3'MULTIPLE CASINGS?[]YES ANO WELL CASING DIA: NIL <br /> 0 EXTRACTION []AIR HAMMER/DRIVEN CASING THICKNESS AJA TYPE OF CASING: U STEEL []PVC []OTHER: . <br /> a VAPOR []MUD ROTARY DEPTH OF GROUT SEAL NQ TREMIE TYPE TO BE USED: []AUGERS []HOSE <br /> a AIR SPARGE 'PUSH POINT GROUT SEAL PUMPED: []Yes xNo (NOTE: MAXIMUM FREE-FALL DEPTH IS.30') <br /> 0 SOIL BORING []HAND AUGER APPROX.BORING DEPTH IS--to, [] BOLTED TRAFFIC BOX or 1]STOVE PIPE <br /> 0 OTHER- [] OTHER CONDUCTOR CASING PROPOSED?�N Iq (it YES,list specifications here): <br /> COMMENTS: D;/ccs P✓sh r,* (,;u clrctt 1v J irS 11 far.00/w. t"d�g L1¢.11 <tt5idg��Git�✓r + �vwat[_ <br /> aAo !n. - Ui k 1 / ✓ /(Mi r <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMI S <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: "I 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 Califomia." 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 Caliromia." <br /> PLICANT M�US�TCALL 48 S IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> / <br /> Signed x IMI) < IIS) Title 3� <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED <br /> DEPARTMENT USE ONLY q <br /> Application Accepted By Date Issued ! 6 Area av <br /> Grout Inspection By Date Final Inspection By Date �� <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: A10# <br /> FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> 0 r. Z- D <br /> C STOFiD.CCN Tt� T01 ' S` ' C ,tTCE1� BtC�T�RzrrrIllt ' ' f )uG ) 'I`�QIt <br /> UNIT IV-6/23/99/sign bkpg/MI <br />