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9-22-1999 A:OOPM FROM P. <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION ("PHS-EHD") <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3450 <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 compliance with <br /> San Joaquin County Development Title.Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental <br /> s Assessor <br /> Division. <br /> X99 500411 LC0114 ST. Cross Street `dl ily7wlo City Sryektan Z-915)06 Parcell j6S-03-005 <br /> WELL Location o i A. 1>hn�,�r�•y�d��t`f <br /> OOA- J2� ss Adtiref O`�C� � T • . cty 1Y<' C zip SL / <br /> PROPERTY Owner t� �t o t, f$37 9.? 313-58ea <br /> C-5TContractor(>'1' c11 U MMS Address ys0 notuf '1d C`ity 1�1`eLz�inpMy.1 q5 Li L�Lry—sem Phone# 5' <br /> V71 � p� J'T. cityv .._Lict! i+/�JPhonest'17D�`� y8S0 <br /> consultant/Sub Contractor C,awlbr I u N V Address rZ� ! <br /> Township Range Section <br /> GIS Coordinates:X Y--. <br /> WORK TO BE PERFORMED <br /> ' DESTRUCTION(choose type below) <br /> NEW WELL/BORING(CPT.GEOPROSE. HYDROPUNCH. HAND-AUGER.OTHER') W 16 OVER-BORE <br /> 0 SOIL BORING# Q PRESSURE GROUT <br /> 0 WELL 9 <br /> "Other: <br /> Cc:MMENTS: ,/ <br /> OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATI MULTIPLE CASINGS?0 YES Q NO WELL CASING DIA: — <br /> _.JNITORING HOLLOW STEM DIA.OF BOREHOLE,_._ <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS SCA Nl) TYPE OF CASING: <br /> TYPE TO BE V(PVED: 0 U OTHER:GERS oHOSE <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL <br /> 0 AIR SPARGE O PUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 <br /> HAND AUGER APPROX. BORING DEPTH — 5'1 0 BOLTED TRAFFIC BOX or J%;OVE PIPE <br /> 0 OTHER: CONDUCTOR CASING PROPOSED? (if YES, list specifications here): <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PER <br /> thereby rf,and Reg ationsJoauin Countyhoat I have prepared this f the San Joaquin C unty.11 Homeowner Or licensed gent's s gnatucatm,and that the orkwill be cone in re certries hetfoll wing: "I certify thaOt in'tfre pe �t ce of o work <br /> !or which this permit is issued,I shall not employ persons subject to WORKMAN'S COMPENSATION Laws of California." Co�tr;ctof s hiring or sub- <br /> rformance of the work for which this permit Is issued/shall employ pe s subject to <br /> contracting signature certifies the following: '!certify that N the pe <br /> WORKMAN'S COMPENSATION Laws of Celifomia.' <br /> HE APP NT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> /7 ut TiUe <br /> Signed z <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED <br /> DEPARTMENT USE ONLY <br /> Date Issued OIC Area <br /> Application Accepted By 10. - _Date <br /> Date D 1 Final Inspection By � <br /> Grout Inspection By J <br /> Destruction Inspection By Date <br /> ^7MMENTS/CONDITIONS: <br /> FAC% <br /> ACCOUNTING ONLY: AID# <br /> SH RECEIVED BY DATE PERMITISERYICE REQUEST NUMBER INVOICI <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKWCA <br /> 5O Z <br /> -466 , 00 1 136 9 Z — <br />