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WELL PERMIT APPLICATION FORM UNIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 \v a <br /> (209) 468-3449NON0� <br /> Application is hereby made to San Joaquin County I Dr a permit to constABLE ruct and oIT Eirt tallS I EheRwork described— <br /> .FROM SThis application San Joaquin county Development Title,Chapter 9-7115.3 antl the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br /> // Pp on is made in compliance with <br /> WELL Location('YIR C0,1VAL ` TIIokNTon Arf)O <br /> Cross Street C ,agL A" City [�/j i Zip y'S��.Assessor's <br /> PROPERTY Owner �i ILNgRHP <br /> Q C r ,De� _ <br /> /� lU Address(4?) Cgp4AL Ay.e City L0D2 Parcef# 6$5-32.; —2-7Zip`52VA phone# 2o5_ 3 <br /> C-57 Contractor 17 , 6 , i_ _ Addresst /hi^Cmu 5,, 4111-7 <br /> Consultant/Sub Contractor_/y, C City hz Zip92'4 Lic# $n227Phone 7l 996 <br /> ' ' —Address 9 c,o5 N, w;ls_�n�W y <br /> City Sio�l<T Lic# br�Z2 Phone Zo"l V� /- i <br /> GIS Coordinates:XY 7 k <br /> —�,Townships Range _ <br /> WORK TO BE PERFORMED /����/� Section _ <br /> NEW WELL/BORING(CPT GEOPROB ,HYD PUNCH HgN I A GER , /`!A�_�_w-yb-- <br /> �jQ P- Y is �_�) PyD�ESTRUC710N choosetype below) <br /> 'Other: DWELL# ING# Y'b j� r_� lO r�-rI,PIZt��t���R�R 0OVER-BORE <br /> COMMENTS: 8,,,i,, S A!v.c c S Fe c r ' 0 PRESSURE GROUT <br /> � <br /> TYPE OF WELL �- 6 o S=II- <br /> INSTAL�IONN CONSTRUCTION SPECIFICATIONS <br /> D MONITORING 0 HOLLOW STEM i <br /> 3 EXTRACTION DIA. OF BOREHOLE_ MULTIPLE CASINGS? YES <br /> 0 AIR HAMMERIDRIVEN CASING THICKNESS NIR 0 ONO WELL CASING DIA:^%IR <br /> 3 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TYPr}E OF CASING: p STEEL p PVC 0 OTHER: IV 4- <br /> 9 AIR SPARGE 7;c4 AL DO-f TREMIE TYPE TO BE USED: �., <br /> �USH POINT GROUT SEAL PUMPED: 0 Yes -*o (NOTE: MAXIMUM FREE-FALL DEPTH S 30') <br /> SOIL BORING 0 HAND AUGER <br /> a APPROX. BORING DEPTH .57 Fez}BX <br /> ] THER: 0 OTHER O BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? <br /> (if YES, list specifications here):— <br /> =OMMEN7S: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> 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 ind Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: "I ceKify that in the performance of the work <br /> onwhich this permit is issued,I shall not employ persons subject to WORKERS'COMPENSATION Laws of California." Contractor's hiring or sub- <br /> certifies ting signature certifies the following: Y California " that in the performance of the work for which this permit is issued, I shall employ <br /> ✓ORKERS'COMPENSAT/ON Laws of ng:-1 certify <br /> ia." <br /> P y persons subject to <br /> HE APPLICANT MUST CALL 48 WORKING HRS IN ApyANCE FOR ALL REQUIRED INSPECTIONS. <br /> ,ignedx 1, ,TIJ //_'� <br /> Title_R8,, i pd2c, ate '�3 o9 co <br /> SEE SITE A N UNIT IV WORK PLAN DATED: <br /> q <br /> pptication Accepted By DEPARTMENT USE ONLY <br /> -rout Inspection By Date Date Issued <br /> estruction Inspection By Final Inspection By Area <br /> to <br /> OMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# <br /> RECD BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 3501 6b 6A /3 4�A 3-.a DD ZZizS <br /> IT I LICENSED CONTRACTOR MUST SIGN LICENSE &WORKERS' COMPENSATION DECLARATION <br /> NIT IV- 6/23/99/sign bkpg/MI <br />