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r <br /> 1-1999 3: 13PM FRON' P. 3 <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES i <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-34493 <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 County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br /> f <br /> WELL Location 11GS Cross Street City Assessor's <br /> C S Zip I ' Parcel# 28Z-1 ?o-o'J <br /> PROPERTY Owner Erv+ie Qc 3-.r Address (755 6J: I( <-F> City ..11 V c Zip 9537d"Phone#209^33.5-gpqS <br /> C-57 Contractor Oro q Q b"r s7 Address__75b kot-me Rd City hCLr'�w�;I:zP c# 444hone# 9' -S13-��2� <br /> Nr4(,0- FT <br /> I"a.R't� S�.S"f¢..•«t Address 'f78S3 �avr•,Sp�-+9tCity� <br /> Consultant/Sub Contractor e'`^"+-�LicK Kl Fho+ie#flu��i��-a37.0• <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> 0 NEW WELL/BORING(CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> >�C OIL BORING#_1°QT^ 0 OVER-BORE <br /> 'Other: WELL# 0 PRESSURE GROUT <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE a`t MULTIPLE CASINGS?0 YES ;WNO WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> p VAPOR 0 MUD ROTARY DEPTH OF GROUT SEALF,.TREMIE TYPE TO BE USED: GAUGERS HOSE <br /> VF <br /> ]AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: , Ves 0 No^(NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> ]SOIL BORING 0 HAND AUGER APPROX. BORING DEPTHQ BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> OTHER: C OTHER CONDUCTOR CASING PROPOSED? (it YES,list specifications here): <br /> 'OMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> 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 /> ind 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 /> `or which this permit is issued,I shall not employ persons subject to WORKERS'COMPENSATION Laws of California." Contractor's hiring or sub- <br /> =tracting signature certifies the following: 'I certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to <br /> NORKERS'COMPENSATION Laws of California.' <br /> APPLIC N UST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS). <br /> iigned x & Title IAA�ate <br /> SEE SITE AP IN UNIT IV WORK P DATED <br /> DEPARTMENT USE ONLY O <br /> Npplication Accepted By Date Issued Oro Za0 <br /> rout Inspection By Date Final Inspection By ate <br /> )estruction Inspection By Date <br /> ;OMMENTS/CONDITIONS:_ 0 . <br /> 42,1 2- <br /> ACCOUNTING ONLY: AlD# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> 2a0 2." 28br 5 - SR# Z <br /> C47-VCENSEII-CONTE-KCr 4R 11US 'SI TCEN & ORKER E?A�II' 5° ON p MOR t <br /> ONIT IV-6/23/99/sign bkpg/MI <br />