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0712/99 09:42 RU �02 <br /> r oo� o- i ru.+ri r rtur• <br /> ! WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES FILE <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA„ 95202 <br /> (209)468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application Is hereby made to San Joaquin County for a permit to construct arrvgr Install the work described. This application a made in compliance with <br /> San Joaquin County rrDevelopment Tit <br /> le <br /> ,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Service,.Environmenbl Heehh�DH^7s�ian'/ <br /> WELL Location M�� l I/ Ir �t rl/ Cross Street City Tp Parcels <br /> PROPERTY Owner �,J. I� {P<� Address�1 :. �, r,"y <br /> ��2_ ,�-��� CM1y 1�,r,E _Zip Phdne#�-. 7-�y <br /> C-57 Contractar�_;$i 11; 4'IC Address �r% -.l�X �I'1/� 'C/ity )GN 7JpT'+J71/ uO{ Phorx,/Yl7/C,.,%7/� _7�iCS <br /> Consultant.Sub Contracts! V\ll lVl f:vh !"1�y,'n! ✓ AddrestijZ (kwg VKet ITity�',r;G:�+!I� pa Phone'lr(W-772I <br /> GIS Coordinates.X v Township Range__ Sedt,Qn_ <br /> WORK TO BE PERFORMED - --'- - - <br /> Q NEW WELL:BORING I CPT, GECPROBE HYDROPUNCH, HAND-AUGER.OTHER') CESTRUCT10y(cntiose type beb'.v) <br /> Q SOIL BORING <br /> O WELL# # �'y'// C 1{// <br /> �.5 CG C iV OVER-BORE <br /> 'Other, Q PRESSURE GROUT <br /> COMMENTS. <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING 11 HOLLOW STEM DIA. OF BOREHOLE MULTIPLE CASINGS'Q YES Q NO 'NELL CASING CIA._ <br /> a EXTRACTION Q AIR HAMMEWORIVEN CASING THICKNESS TYPE OF CASING Q STEEL Q PVC a OTHER <br /> ]VAPOR all ROTARY DEPTH OF GROUT SEAL,3 b 4U� TREMIE TYPE TO BE USED: )%hUGERS OHOSE <br /> Q AIR SPARGE Q PUSH POINT GROAT SEAL PUMPED. ))Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> a SOIL BORING Q HAND AUGER APPROX.BORING DEPTH <br /> Q BOLTED TRAFFIC BOX or a STOVE RIPE <br /> a OTHER'. Q OTHER CONDUCTOR CASING PROPOSEC7__i d YES,list specifications here): <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> nerebY CeNfy that I have preoared?his application and that:he work will be do"in accordance with San Joaquin County Ordinances, Sate Laws,and R¢�s <br /> and Regwauons of the San Joaquin County, Homeowner or:Icensed agents signature certifies the fonowsg'^t certify thet in the performance ofihe work <br /> for welch this permlf is issued,I sfm/l not employ persons sub/ecl to WORKERS'COMPENSATION Laws of Cetifom/a." Contractors hiring ore w <br /> ;omracting sgnalure certifies the fpllp.N g; 7 certify Ural if,the paAore ane,of the work rk for which this parmnls issuer..:shad employ persons sudrecr is <br /> NOPKE.RS'COMPENSATTON Limp Cahramm.' <br /> ppTHE PLIC9T MUST CALL 48 HRS IN ADVANC FOR ALL REQUIRED INSPECTIO <br /> N <br /> S: <br /> 3ignedYy_� r Date <br /> SEE SITEMAP UNIT IV WORK PLAN DATED <br /> DEPARTMENT USE ONLY <br /> 1ppleation Accepted By Date Issued <br /> 3rcut Inspection By_ Date Final Inspection By <br /> )espUCtion Inspection By Date ds Ipy(f <br /> ,OMMENTS I CONDITIONS: . <br /> ACCCUNTING ONLY I AID* FACM <br /> PE CODESFEE INFO ! AMOUNT REMITTED CH ECK#lCASH RI EKED By DATE I PERMITISERVICE REQUEST NUMBER INVOICE21 UJD ��Q <br /> i <br /> C-5'I1CF-LASED CO3/TRACTOR MUST SIGN-LICENSE':&WQRIERS COATPF.NSk 707AT DECL.ARAT710 <br /> )NI P/-6/23/49/s+ n b - " <br />