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WELL PERMIT APPLICATION FORT ',-- { <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVE <br /> I <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EH�--��" - <br /> 304 E. Weber, Third Floor, Stockton, CA., 9'5202 AUG 0 9 1999 <br /> (209)'468-3449 ENVIRONMENTAL HEALTH <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT /SERVICES <br /> Application is hereby made to San Joaquin County for a permit to construct and/Qr install the work described. This application is made in comp lance 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 /> WELL Location 2 � T �� Cross Street ��'d Cit 5,�� Division- <br /> Assessor's <br /> //� ,� y Zip 9.r ZParcel# ly,J-67,0- O/ <br /> PROPERTY Ownerd/e,,Cr' 5;2t� +� Address�5_�• CZ d City ra �� Zip9�oZ Phone `l !J T-&"1% <br /> C-57 Contractor pmcc,S w /1AddresssY <br /> �f� s � � <br /> � - ��N <br /> 1CiityAJ Zip �Lic#b VS�'7 <br /> Consultant/Sub Contractor" W-I Vii-+ 4d1 u/ Address�01 l�/ 'h' City��/a�� Lic# Phone#�!>�3��/��a <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> 0 NEW WELL/BORING (CPT.GEOPROBE, HYDROPUNCH, HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> 0 SOIL BORING# ,b'-/ — /�-y 0 OVER-BORE <br /> WELL# JVPRe99fRE GROUT <br /> 'Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE Z MULTIPLE CASINGS?0 YES 0 NO WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL —_ro� TREMIE TYPE TO BE USED: `AUGERS BHOSE <br /> 0 AIR SPARGE -f/PUSH POINT GROUT SEAL PUMPED: 0 Yes JrNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH -k-TO/ 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER: 0 OTHER CONDUCTOR CASINGjPROPOSED7 r (if YES, list specifications here): <br /> COMMENTS: 2 / nlJ� S. `r� A <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I 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 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: 7 certify that in the performance of the work for which this permit is issued. I shall employ persons subject to <br /> WORKERS'COMPENSATION Laws of Califomia." <br /> r <br /> THE APPLIC T T CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> J'r <br /> Signed x Title S�fCtirl�� Date <br /> SEE SITE MAP U IT IV WORK PLAN DATED <br /> DEPARTMENT USE ONLY <br /> 99 i <br /> Application Accepted By Date Issued �'��` / Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: FAID# <br /> FAC# <br /> PE COOES FEE INFO I AMOUNT REMITTED CHECK#l. ASH RECEIVED BY DATE PERMIT/SERVICC3E//R��EQUEST NUMBER I INVOICE <br /> C 57 IICEly�EII... TRACTQRNl E',SF LECEi�IS .&WQR. s _CC3i I' St I N_F} ATO <br /> UNIT IV- 6/23/99/sign bkpg/MI <br />