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. ORIGINAL <br /> WELL PERMIT APPLICATION FORM UNIT IVLkTED <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 FILE� CSP <br /> (209) 468-3449 <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/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 /> Assessors <br /> WELL Location jCA70 p�'"Yl�tQC4. ST' Cross Streetf � (AINI City f}/nA,9c)ic Zip p Parcel# <br /> PROPERTY Owner,1tJSCc, I"IA2"T)1l, rZ. Address l3� L.t44(�lIbUXbttl7Cty r..U,Y/,J,(,L,{� Zip IS Pho��e#7 774-3` 10 <br /> C-57 Contractor Wt_Y,-,u_!APn ( Address Yr O, 0,-,�DX 35i(o CitY--\., il4 Zip9�s�I Lic#]jOC Ph�ne3i SCI —'Qi00 <br /> 2 gl <br /> Conultant/Sub Contractor. -i CS� N <br /> e,00eAf)CI'J Address N-2Z . MA XZ1 <br /> s6y—&n,._Lic# Phonew <br /> # qat-�3350G <br /> Su.�y iG i <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED <br /> *NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE <br /> WELL# E PRESSURE GROUT <br /> -Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> AONITORING 16,01.1-OW STEM DIA. OF BOREHOLE tl MULTIPLE CASINGS?0 YES 'b*O WELL CASING DIA:c9�t <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS SGA' 0 TYPE OF CASING: 0 STEEL %PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL Z I r TREMIE TYPE TO BE U ED: 0 AUGERS *OSE <br /> 0 AIR SPARGE p PUSH POINT GROUT SEAL PUMPED: p Yes <br /> J "o (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER APPROX.BORING DEPTH `rIc VOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER: tl OTHER CONDUCTOR CASING PROPOSED?a(if YES,list specifications here): <br /> COMMENTS: <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 Rules <br /> and 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 /> 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: •I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to <br /> WORKERS'COMPENSATION Laws of California.' <br /> T APPLICANT MUST;:C{ALL 48;WORKING HRS' IN A_DVnANCE'FORALLfiEQU1RED INSPECTIONS. <br /> Signed G 1G .wnU(e V Loi . Date U / Ig loo <br /> C- I <br /> SEE SITE MAP I N T IV WORK /PLAN DATED: N_T 1 ,5, Z000 <br /> DEPARTMENT USE ONLY / 3- �y/ <br /> Application Accepted By L'� Date Issued t✓ �+ �U Am, -�' <br /> Grout Inspection By Date Final Inspection By Date -22-40 <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: ZZ ZOCd 'f' <br /> C• s7 iii <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> -z7 2-3 <br /> C-57 LICENSED CONTRACTOR MUST SIGN LICENSE&WO"EWS'COMPENSATION DECLARATION <br />