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9-22-1999 A :oopM FRUM . <br /> ORIGINAL <br /> UNIT IV <br /> / � ?Mei WELL PERMIT APPLICATION FORM <br /> ,ren Z <br /> fJ SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> jy� GG� ENVIRONMENTAL HEALTH DIVISION ("PHS-EHD") `l <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 „ <br /> { (: L (209) 468-3450 =` <br /> /lel L,Q - . <br /> 1v-/1-50 NON-REFUNOABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> -4�2 ,yo <br /> Application is hereby made to San Joaquin County for a permit to conswa and/or install the work described. This application is made in g001 lance wltn <br /> Assessors <br /> San Joaquin County Development Title,Joaquin <br /> 9-t 115.3 and the Standards of San Joaquin County Public Health Services. Environmenyjeafth Division. <br /> p � � I Parcel#/60-l7 -D!d <br /> OWAI0.N4iM INUIT Cross Street 1: 5 City J�tc—)d <br /> WELL Location - <br /> 1 D ,f� C.kw Zip Phone#! O 7 <br /> PROPERTY Owner LIVQI �p-sfJCVheS Lrd Address� � ot)Xp 7E5�� CAyI Z �. ,,__,Ly /6SPhone# /�5y I3' SBO� <br /> !pq PT��,IYLQ Address 95o Mrowt M1Gl—AC 1 PYy55S <br /> C-57 Contractor�V-C� --�— <br /> ' <br /> Consultant/Sub Contractor Camwig <br /> Address� D• Qok �Jr�_�ib- -L'c't Pnonea7a7-r3S-YSS0 <br /> J Y J Township <br /> Range Sectwn <br /> GIS Coordinates:X <br /> WORK TO BE PERFORMED <br /> ' p DESTRUCTION(choose type below) <br /> NEW WELL/BORING (CPT, GEOPROSE, HYDROPUNCH.HAND-AUGER, OTHER Q OVER-BORE <br /> a SOIL BO"",- " Z�y .01-$0 I*'7- 0 PRESSURE GROUT <br /> WELL# ^=�' _ <br /> •Other: tt/ bra 2 foS Z^YOD 2'I lO- s <br /> COMMENTS <br /> TYPE OF WELL CONS RUCTION E CO rTRUGT N SPEC F1CAY10 �,•,,, WELL CASING OIA:e�_ <br /> XMONITORING /-)f STEM DIA.OF BOREHOLE_MULTIPLE CASINGS'a YES R'""+ <br /> g EXTRACTION J/0T `0 AIR HAMMER/DRIVEN CASING THICKNESS tnln yD TYPE OF CASING 0 STEEL PVC Q OTHER:_ <br /> f]VAPOR a y�MUD ROTARY DEPTH OF GROUT SEAL reT i TREMIE TYPE TO BE USED: AUGERS or r$'HOSE <br /> Q AIR SPARGE Q PUSH POINT GROUT SEAL PUMPED: )'Yes B No (NOTE:BOLA IMU FFR BOX or FEE-FALL pDEPTH <br /> STOVE P PE <br /> SOIL BORING D') <br /> Q D <br /> HAND AUGER <br /> APPROX. BORING OEPTH4 L7D JL __)( r <br /> OTHER: CONDUCTOR CASING PROPOSED? (if YES,I1st specifical �ere):~��rSICC-� <br /> E <br /> (QAAW,t2Z 010 <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIAE ACCESS OR ENC OACHMEN I PERMITS' <br /> and Rules <br /> and Regulations e Laws, <br /> not the San Joaquin Count) Homeowner or licensed agentt''sdsignaturrone in e ertfest 6tf Soan•�gagi_eCDoYth t in Orth us �miance of the work <br /> for which contracting his Permitre is certifies the following:tl certify That in the Performance oemploypersons subject to f the work(orwh <br /> OMPh this permit ENSATION t i5 issuedws Of. <br /> j shaall memploy persons subject to sub- <br /> WORKMAN'S COMPENSATION Laws of Califomia.' <br /> THELICANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> signed <br /> ' I/!t 4" l .��1-eZI Title�!'r�i S_ LOL(7,0� ate n z <br /> t �'1 <br /> Z <br /> SEE SITE MAP IN UNIT IV WORKPLAN DATED <br /> DEPARTMENT USE ONLY 12 /71�7t �J _ Area <br /> Date Issued <br /> Application Accepted By Date <br /> + r fir' to 'S <br /> Date Final Inspection By _ <br /> Grout Inspection By <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> FAC# <br /> ACCOUNTING ONLY: AIDS <br /> NUMBER INVOICE <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK##CASH RECEIVED BY GATQQE'' PERMITISERVICE�E��� <br /> 0 <br /> e47 ✓max, we <br />