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y-1'1—lyyy <br /> 4:VJVJYI`- _ rn� <br /> UNIT W <br /> WELL PERMIT APPLICATION FORM <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH HS SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION CA 95202 <br /> 304 E. Weber, Third Floor, <br /> Stockton, <br /> (20g) 468-3450 <br /> NON•REFUNOABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> lication is made in compliance with <br /> Public Health Services.Environmental Health Division. <br /> Permit to construct andfor install the wort described. This app gssesso(s <br /> Application is hereby made to San Joaquin County for a p � - Z'F 95W Parcel#�— <br /> San Joaquin County Development Title,Chapter 9-Itt53 and the Standards ofSan <br /> 9d6G�Prtpne#/yfQ �'s . <br /> L V _Cross Street CC GG1l j..&Q zip <br /> WELL Location -ilq W C;:4V'1'e� / !j a �(rlu ST clty/ +•,m` <br /> �f, C p)t)CS _Address li/A)Lic#041/07Phonell9at� <br /> PROPERTY OwnerJ��r r`14(t� d / Ciry Qf Z LP <br /> y Lh S I tU Address ISO /5 F / PtronaM1 7,17-f <br /> C•57 Contractor 111�n�.n7- '� R7D city <br /> J �L� 'T <br /> "I/ Q � 1'6 SeAddress 6 Secuon_,� <br /> Consultant)Sub Contractor! Range�-- <br /> Y�Township��— <br /> GIS Coordinates:X�— <br /> WORK TO BE PERFORMED p DESTRUCTION (choose type below) <br /> OVER-BORE <br /> 2c T Q PRESSURE GROUT <br /> Q NEW WELL I BORING(CPT,GEOP�RGE NG#DROPI +I"1.H NO-AU ER.OTHER' <br /> WELL# <br /> •Other: WELL CASING DIA:�,� <br /> COMMENTS: " MULTIPLE CASINGS?p YES NO <br /> TYPES CO14 1 RU,�YPE CONSTRUCTION SPECIFICATION pvC a OTHER: <br /> HOLLOW STEM DIA.OF BOREHOLE TYPE OF CASING: p STEEL 0 AUGERS CHOSE <br /> t)MONITORING TREMIE TYPE 70 8E USED: Q <br /> rU EXTRACTION Q AIR HAMMERIORIVEN CASING THICKNESS <br /> U MUD R07AR 1 DEPTH OF GROUP SEAL— STOVE PIPE <br /> ` y� 0 No (NOTE_ MAXIMUM FREE-FALL DEPTH IS SD <br /> t)VAPOR �•dr'J GROUT SEAL PUMPED: 0 0 BOLTED TRAFFIC 80X or Q <br /> PUSH POIN `T <br /> �AIR SPARGE APPROX. BORING DEPTH-------- (1f YES,list specifications here): --� <br /> SOIL BORING D HAND AUGER <br /> CONDUCTOR CASING PFOPOSED7 <br /> OTHER: <br /> CommENTS: ENT PERMITS! <br /> OFFSITE BORINGS REQUIRE A <br /> CCESS OR ENCROACHMENT -and <br /> NOTE: g y Prformance of the worts <br /> I hereby cenrfy Ihet I nave prepared Ih1a application and that the woM <br /> will be da one in accordance with San Jaagl certi( that in the p r State aw , <br /> r which this permit is issued. 1 shall employ persons subject to <br /> ersons su a a to WORKMAN'S COMPENSATION Laws of California.' Contractor's hiring or su <br /> and Regulations of the San Joaquin County. Homeowner or livens�d ageni s signature,certifies the following; <br /> for which this permit is issued,1 shelf not i art' t in tha per(ermyrca of the worK(o <br /> signature certifies the touowing: • ALL REQUIRED INSPECTIONS. <br /> contracting 9 <br /> ppL T MUST CALL 48 HRS IN ADVANCE FOR. � /,)O ale r� <br /> yvORKMAN'S COMPENSATION Laws of California-* <br /> Title <br /> Signed x DATED <br /> SEE SITE MAP IN UNIT IV WORDEPARTM PENT LAN SE ONLY <br /> Date Issued <br /> � Oate� <br /> Application Accepted By Date l 'o Final Inspection BY <br /> n <br /> Grout Inspection By Date <br /> Destruction Inspection By <br /> COMMENTS I CONDITIONS: <br /> FAC% <br /> ID# <br /> AINV' <br /> PE CODES FEE INFO AMOUNT REMI <br /> ACCOUNTING ONLY: RECEIVED BY DATE PERMITISERVI REQUEST NUMBER <br /> TTED CFI O�n CASH - <br /> �� V <br />