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9-22-1999 A:OOPM FROM . • <br /> WELL PERMIT APPLICATION FORM <br /> UNIT IV <br /> SAN jOAQUIN COUNTY PUBLIC HEALTH HS-EH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION ( FILE COPY <br /> 304 E. Weber, Third 9)468 Stoc3450kton, CA-, 95202 <br /> 1 YEAR FROM DATE ISSUED <br /> NON-REFUNDABLE PERMIT EXPIRES <br /> Public. This Services,Environmental Health Division. <br /> zpy5al Assosso's <br /> wit <br /> to San Chapter 9.11 t 5.3 and the Standards of San Joaquin County Portal# 00- <br /> Applicaaouin County Develop ant JoTitaquin County for a permit to construct and/or install the work County <br /> described. This application is made in comp lance vi <br /> n's hereby <br /> e. <br /> San Joaquin City <br /> 3011 W 4e� 1Gxnlh I-1'0It blr. _C ossStreet� �fo oc cv� Zia Phone# <br /> WELL location / P p $OX 7676 Cay�2—.�— �,�13•sgaa <br /> V,,,I t t Ltd Address��--�� <br /> PROPERTY Owner LI c�, V 1 Zipf� Li�#Y$Jr�t: Phonelt <br /> I Addressys0 ffptV'2 P.c <br /> C-57 Contractor 4 � o✓Iom L,co Pnonett 707-9_ ; <br /> Address n tl �p)C a5y City <br /> �alntbV'I C� Secbon�� <br /> Consultant/Sub Contractor 7oRange�— <br /> wnsrtiP�.—�— <br /> GIS Coordinates:X_­--� <br /> WORK TO TIO <br /> BE PERFORMED p DESTRUCN(choose type below) <br /> -r f]OVER-BORE <br /> ( H. I�� �• <br /> NEW WELL f BORING(CPT,GEOPR06E,HYDROPUNCH. a PRESSURE GROUT <br /> HAND-AUGER-OTHER <br /> if <br /> SOIL BORING tt <br /> $'WELL# <br /> *Other, o OI firms ' <br /> CwAMENTS: TRU ION SPECIFICATIONS ' YES NO WELLCASING DIA: _ <br /> TYPES CO SCO S R C MULTIPLE CASINGS PVC a OTHER: <br /> HOLLOW STEM DIA.OF BOREHOLE TYPE OF CASING: U STEEL <br /> YMON17ORING AUGERS CHOSE <br /> 4.0 <br /> 8 EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS S TREMIE TYPE TO BE USED: <br /> MUD ROTARY DEPTH OF GROUT SEAL NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> r�VAPOR GROUT SEAL PUMPED: ayes U N0 I / STOVE PIPE <br /> PUSH POINT r )(BOLTED TRAFFIC BOX or (] <br /> a AIR SPARGE APPROX. BORING DEPTH, �A list specifications here):�� <br /> Q SOIL BORING p HAND AUGER 0 (if YES. <br /> CONDUCTOR CASING PROPOSED7�_ <br /> OTHER: <br /> COMMENTS: <br /> ENT PERMITS- <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHM and Rules <br /> Ilcation and that the work will be doge in accordance with San Jaquin County Ordinances.Stale Laws, <br /> 11 <br /> f sub- <br /> nereby certify that 1 Rave prepared this aPP Homeowner or licensed a ant's s nature certifies the following: I certify that in the Performance of the work <br /> anu Regulations of the San Joaquin County. <br /> 9 <br /> I certi that in the performance of the work for which this permit Is issued. 1 shell employ persons Subject to <br /> for which this permit is issued,1 shall not employ persons subject to WORKMAN'S COMPENSA7lON Laws o/California." Contractor's ,nng o <br /> contracting signature certifies the following' fl' <br /> yvORKMAN'S COMPENSATION Caws Of California'. / 1 1A _ 0( — <br /> L 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS— <br /> NS- <br /> THE APPLICANT MUST CALfa?e rT �j�d�0tlrSTDate <br /> Title <br /> Signed x <br /> SEE SITE MAP IN UNIT IV WORDEPARTM PNT uSE lAo LYDATE 6 _z9.o / , e� Of- <br /> Date Issued Date_— <br /> Applimtion Accepted By Bate____�Final Inspection BY <br /> Grout Inspection BY Date <br /> Destruction Inspection BY <br /> COMMENTS I CONDITIONS: <br /> FACX <br /> ACCOUNTING ONLY: <br /> AIDC <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK CASH RECEIVED BY LAneC PERMITISERVI REQUEST NUMBER INV <br /> SO `P' /.3 U ! 6 <br />