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WELfPERMIT APPLICATION *FORM UNIT IV ,�n1 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ��'•` <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) 647- <br /> 304 E. Weber, Third Floor, Stockton, CA.,44 9520 ` ���i! <br /> (209) 468-39 �ILE S <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 Count Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Healt Division. <br /> Covn n 0 F_ onSTAA . 5To9A 51(jeq-I- _ Assessor's Fiu�T of `` <br /> WELL Location 9 — �Cros#Street CAbioL Aveme Cfty Lo o i- Zip 9S_ a4.z Parcel# X ra -'52,-z5 <br /> KioHHAD ISoKiDc} of p <br /> PROPERTY Ow1ne1r_IFIA C ) rill Address ( 9,?J CAAr AL il)y _ City L oz- Zip9�Phone# 2� 367 9 5C <br /> C-57 Contractor_WEST HA2 A��'� Address_3a dJ3 �1�2yP(c,1-0 $;i City R�AOµoF1 Zip9579ALic# 55-1 'Pf�one 9I6 -7 <br /> n CC ba./ <br /> Consultant/Sub Contractor A . �. C Address 106 AJ, if l'bin City STIK7PnLic# 22 Phone 20 p), <br /> GIS Coordinates:X Y ,Township � AJ Range 7 Section_ <br /> WORK TO BE PERFORMED <br /> NEW WELL/BORING(CPT EOPROBE, HYDROPUNCH, HA D-AUGER,OTHER-) D DESTRUCTION(choose type below) <br /> SOIL BORING# 0 OVER-BORE <br /> ^WELL# 000 PRESSURE GROUT <br /> 'Other: <br /> COMMENTS. <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE Q ie-r-4 MULTIPLE CASINGS?0 YES 0 NO WELL CASING DIA: <br /> 0 EXTRACTION D AIR HAMMER/DRIVEN CASING THICKNESS�I A _TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: NIA- <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 1,.fAL 0 7 TREMIE TYPE TO BE USED: D AUGERS >HOSE <br /> 0 AIR SPARGE %PUSH POINT GROUT SEAL PUMPED: /brYes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH 15 v F£CI- (•iXrD BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER:_0 OTHER CONDUCTOR CASING PROPOSED?N�_(if YES, list specifications here): <br /> COMMENTS: 1'T4Cin nn CP"— �l�ct 1'rv:G prJE ASI JI.� , < ' [ /tSTF,�[1 diel) � I1 h£ <br /> L D i�— i� 6ci F Co wc, <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS R ENCROACHMEN 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 Rules <br /> and Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: "I certify that in the performance o1 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 /> .ontracting signature certifies the following: '/cerlify that in the performance of the work for which this permit is issued, /shall employ persons subject to <br /> !✓ORKERS'COMPENSATION Laws of California." <br /> THS APPLICANT MUST CALL 48 WORKING HRS INA VANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed x Title Q ate 3 <br /> SEE SIT AP IN UNIT IV WORK PLAN DATED: )op,,+ oi� zu o-j <br /> I / DEPARTMENT USE ONLY �c <br /> application Accepted By /.�/}��, Date Issued J �— Area O V <br /> 3rout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> :OMMENTS/CONDITIONS: /C)3 —/V4</ <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 350 �3 3• z Z oZ2.35z <br /> C-57 LICENSED C RAC MUST SIG LICENSE &WORKERS' COMPENSATION DECLARATION <br /> INIT IV- 6/23/99/sign bkpg/MI <br />