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ORIGINAL. <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLI HEALTH SERVICES 1 Y <br /> ENVIRONMENTAL HEALTH E IVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 + WJJ 'WD <br /> (209) 468-34 9 <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 insta I 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 /> Assessor's . <br /> WELL Location 11e0 Cer+ eO AVGY1s1G Cross Street nice cityTr'O' zip 153'76 Parcel# <br /> Lees-. Ward <br /> PROPERTY Owner Wsra tLcdl Estre. Address 103 y <br /> Cerl Fe City T+�c Zip`415376 Phone#WI-836- !`I0+( <br /> Ro.,a1s o <br /> C-57 Contractor cac� Art 11�n Address 3632 (>rACG- Cr-Gie ity Cordova. Zip 95741L Lic#717 SIO Phone# 916-63$- I J 64 <br /> pav�a 4kt-s'o� Ra,•c4�o <br /> Consultant 1 Sub Contractor - n Address 31K0(acid to r 17o City C.rjovd Lic#-72 It Phone#916-63 l- 130a <br /> GIS Coordinates:X ,Y Township Range Section <br /> WORK TO BE PERFORMED <br /> 0 NEW WELL I BORING(GPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) ADESTRUCTION-(choose type below) <br /> 0 SOIL BORING# AVER-BORE <br /> WELL# 0 PRESSURE GROUT <br /> 'Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICA IONS <br /> Q MONITORING 0 HOLLOW STEM DEA. OF BOREHOLEMULTIPLE CASINGS?0 YES 0 NO WELL CASING DIA: <br /> 0 EXTRACTION 0 Alit HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL t I TREMIE TYPE TO BE USED: 0 AUGERS OHOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED. 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER: 0 OTHER CONDUCTOR CASING PROP SED? (if YES,list specifications here): <br /> c <br /> COMMENT5: Z <br /> e <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 a cordance with San Joaquin County Ordinances, State Laws,and Rules <br /> and Regulations of the San Joaquin County. Homeowner or licensed agent's signatur certifies the following: 'Y 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 wojk for which this permit is issued, t shall employ persons subject to <br /> WORKERS'COMPENSATION Laws of California <br /> T.-. PP IC T,MUST CALLh48 WORKING^HRS IN A` ANCEaFOR`ALI.REQUIREP_1NSPECTIONS <br /> Signed x Title ter ea� ! Date s —2 ct_—o r <br /> SEE SITE M I UNIT IV WORK PLAN DATED: 2 2-VYo4e <br /> DEPARTMENT USE,ONLY J�bgV <br /> Application Accepted By Date Issued ?���o/ Area V O <br /> Grout Inspection By Date Final Inspection By 2 1-0 <br /> Destruction Inspection By IV Date <br /> COMMENTS I CONDITIONS: <br /> F[ACCOUNTING ONLY: AID# <br /> ES FEE INFO AMOUNT REMITTED CHECK# REC'D Y DATE PERMIT/SERVICE REQUEST# INVOICE <br /> SVA7 q-519R# 011 z 3tt <br /> C`5.7-LICENSED;CONTRAGTOR;MUST SIGN LICENSE WORKER5'a CQMPENSA'TT4N DEC!ARATI N. <br /> UNIT IV-6/23/99/sign bkpg/MI <br />