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8-17-1999 1 :59PM FO • P. 2 <br /> WELL PERMIT APPLICATION FORM <br /> 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 /> (2091468-3449 <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/gr 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 /> WELL Location -Z&550 5,-6f-,WT-f\')?-o Cross Street 1 p City T` '-r-y Zip / Parcel# Z 52-1 5V-L <br /> PROPERTY Owner 1�\�VV �f�w�`Uo Address (o(,46 u3- �o_I if+ /�u°-City �V'�C�-/ Zip.9537� Phone# <br /> c• ,rn 5 <br /> C-57 Contractor TVC-, 0 G EaxW-,WC f:"'S Address 13cA 1 L RC,/e r� Ave. CitySAN A�?� Zi W6_bLic# Phone# <br /> Consultant/Sub Contractor TT &.1 RbRA-T 0(--� Address 4�S�o�rCN�cAcotfWGity C:17 Lic# Phone#92�` 0% <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below <br /> NEW WELL/BORING COP, � <br /> D SOIL BORING# 0 OVER-BORE <br /> 0 WELL# D PRESSURE GROU' <br /> *Other: <br /> COMMENTS' <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> D MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE 1.5' MULTIPLE CASINGS?D YES SLNO WELL CASING DIA:_ <br /> 13 EXTRACTION D AIR HAMMERIDRIVEN CASING THICKNESS N /A TYPE OF CASING: D STEEL D PVC D OTHER: <br /> D VAPOR D MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS RHOS <br /> 0 AIR SPARGE )&PUSH POINT GROUT SEAL PUMPED' j'Yes D No (NOTE: MAXIMUM FREE-FALL DEPTH IS 3t <br /> SOIL BORING D HAND AUGER APPROX.BORING DEPTH {UCS D BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> &,OTHER:CC_0 OTHER CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> COMMENTS C I E �"ti <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <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 Ru <br /> and Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: '7 certify that in the performance of the wo <br /> for which this permit is issued,I shall not employ persons subject to WORKERS'COMPENSATION Laws of California." Contractor's hiring or sub- <br /> contracting signature certifies the following: '1 certify that in the performance of the work for which this permit is issued,l shall employ persons subject to <br /> WORKERS'COMPENSATION Laws of California." <br /> THE APPLICANT M TrLL 48 HRS IN ADVANCE FOR ALL RE U1RED INSPECTIONS. <br /> -� Signed x <br /> n �. Title lQ i {+T Date t 4' <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Issued Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> FAC# <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKWCASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVO <br /> OZD 7 8 <br /> C-57 LICENSED CONTRACTOR MUST SIGN LICENSE&WORKERS' COMPENSATION DECLAR.ATIOr <br /> UNIT IV- 6/23/99/sign bkpg/MI <br />