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WELLPERMIT APPLICATION F4M UNIT IV <br /> x SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - <br /> - - - ENVIRONMENTAL HEALTH DIVISION("PHS-EHD") <br /> 304 E. Weber, Third Floor, Stockton' CA., 35202 <br /> (209) 488-3450 <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 compriance with <br /> San Joaquin County Development Titie,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> Assessor's <br /> WELL LocationT 17� C7I� W�/ / Cross Street City Zips Parcel# <br /> PROPERTY Owner ��1� V Address 10 BR&W wr'1 G•tty SfJCk77]'UZfp-LJ2- d5-phone# <br /> f�M f <br /> C-57 Contractor L F�(i li� ss City . T.ip iJc Phone# <br /> i1 i� <br /> Consuttant 1 Sub Contractor�QxaffaU fi7o&If ot�ress 405 l)•�l�1Lr.�'-6W Gity STd�/CILTI Lir- Phone# <br /> E <br /> GIS Coordinates:X Y Township Rang�Ie Section <br /> WORK TO BE PERFORMED j .y <br /> {� NEW VVE-LlL/BORING (CPT. GEOPROSE,HYDROPUNCH,HAND-AUGER.OTHER') j DESTRUCTION (choose type below) <br /> SOIL BORING x 8.1 a OVER-BORE <br /> ]WELL# js 11 PRESSURE GROUT <br /> -Other. <br /> j CCMMENTS: <br /> YPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS j <br /> a MONITORING �H2OLLOW STEM DV,OF E BOREHOLMULTIPLE CASINGS? a Y=5 �§NO WELL CASING DIA: M-19- <br /> 0 EXTRACTI <br /> 19-pJTRACT! <br /> N AIR HAMMER/DRIVEN CASING 7HICKNtSS lIJ/ --^TYPE OF CASING: Q STEEL QPVC p <br /> OTHER: &f4 <br /> VAPOR MUD ROTARY DEPTH OF GROUT SEAL 5 7REMYlE TYPE TO BE USED: 0 AUGERS, DHOSE <br /> AIR SPARGE Q PUSH POINT GROUT SEAL PUMPED: p Yes ')(No (NQTEh: MAXIMUM FREE-FALL DEPTH 15 30'}li <br /> � <br /> SOIL BORING a HAND AUGER APPROX. BORING DEPTH S /9Vr:,�s� (] BOLTED iRAF=IC SOX or (] STOVE PIPE <br /> OTHER: CONDUCTOR CASING PROPOSED? NA (i;YES, list specifications here): <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS? <br /> heret)y reniiy that I have prepared this application and that the work will De done in accordance with San;iloaquin County Ordinances. State Laws,and Rules <br /> and Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the fotlowi6g: "I certify that in the performance of the work <br /> for which this permit is issued,!shall not employ persons subject to WORKMAN'S COMPE:VSAT10N Laws of California," Contractor's hiring or suir <br /> contracting signature certifies',he following: 'I cerffy that in the performance of the work for which this permit is issued. I snail employ persons subject to <br /> WORKI,IAN'S COMPENSATION Laws of Ca&fomia.' li <br /> THE APPLICANT 5T CALL 48 I-iRS 1N ADVANCE I+OR ALL REQUIRED INSPECTIONS. <br /> Signed x Title ��r�Z�G�ac.oUrsr- Date 91'7/9g — <br /> t <br /> SEE SITE MAP I NIT IV. WORK PLAN. DATED <br /> DEPARTMENT USE ONLY iy <br /> Apolication Accepted By Date lssued -i I - � Area <br /> ti ' <br /> Grout Inspection By Date Final Inspec ion Sy �W l�f�.cf� Date <br /> Destruction Insaection By Date jF _ <br /> COMMENTS I CONDITIONS: <br /> FAC# <br /> k I ACCOUN i ING ONLY: AID# <br /> h I PE CODES I FEE INFO AMOUNT REMITTED CHECK-,/CASH I RECEIVED BY DATE f PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> o <br /> UNIT IV-5/99/MI <br />