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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 /> SELI-Location <br /> n Joaquin County Development Title,Chapter 9-1116 3 and the Standards of San Joaquin County Public Health Services Environmental Health Division <br /> Assessors <br /> 2g+313 N. 14WY Cross Street TA NANI RP City 6CAMPO Zrp Parcel# 00 5- 1C-0-19 <br /> {209! <br /> PROPERTY Owner BACIiITAlk 51 N CrH AddraSs P•4• Q X Z 3 5 City <br /> _10 V 11 Zrp b 2 11 Phone# 3 3 ' 19-+1 <br />'C•57 Contractor V4 W (1 CILLI N� Address P1 0 DX 416 city $LE TO N Zip95641 Liar' t10904Phone# -14I9 4i 00 <br /> 3-o51,P0 RA MArrE P 0. Cox 869 <br /> Consultant 1 Sub Contractor R A M A G k E N V 19 0 Address FLA I G H§ M V iR/E T A City °36$ Lich E B S 6 Phono 254-3-L50 <br />'GIS Coordinates X Y— Township Range Section <br /> WORK TO BE PERFORMED <br /> NEW WELL I BORING(CPT GEOPROBE,HYDROPUNCH,HAND-AUGER OTHER-) 1]DESTRUCTION(choose type below) <br /> o SOIL BORING# 0 OVER-BORE <br /> a WELL It MW- Z Q PRESSURE GROUT <br /> 'Other <br />,COMMENTS 1 0{1- StTE McN1109INtr WELLS <br /> TYPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING I HOLLOW STEM DtA OF BOREHOLE_L IN MULTIPLE CASINGS?a YES g NO WELL CASING DIA 2-Ir-1 <br /> TRACTION o AIR HAMMER/DRIVEN CASING THICKNESS k H 40 TYPE OF CASING' a STEEL I PVC a OTHER <br /> POR p MUD ROTARY DEPTH OF GROUT SEAL,_G 6- T T TREMIE TYPE TO BE USED !AUGERS DHO$E <br /> a AIR SPARGE a PUSH POINT GROUT SEAL PUMPED I Yes p No (NOTE' MAXIMUM FREE-FALL DEPTH IS 30) <br /> 1,,SOIL BORING a WAND AUGER APPROX. BORING DEPTH 90-11­ 1 BOLTED TRAFFIC BOX or ()STOVE PIPE <br /> 0 OTHER CONDUCTOR CASING PROPOSED? NO (if YES,list spedfications here) <br /> COMMENTS <br />' NOTE. OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS! <br /> I hereby certify Thai J have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances State Laws,and Rules <br /> and Requtations of the San Joaquin County Homeowner or licensed agents signature cenifies the following I certify that in the performance of the work <br /> for which this permit is issued, I shalt not employ persons sub)ece to WORKMAN'S COMPENSA170AI Laws of Cahfornla" Contractors hiring or sub. <br /> contrachng signature certifies the following "!cerrffy that In the performance of the work for which this permit is issued,I Shall employ persons subject to <br /> WORKMAN S COMPENSAYION of Colffomia" <br /> THE PPnm 11) I. ANT MUST CALL. 48 HRS IN ADVAN144uA&A- <br /> OR ALL REQUIRED INSPECTIONS <br />'Signed x Title Date t7 I <br /> ISEE SITE MAP IN UNIT IV WORK PLAN DATED MAY 211000 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By kL±y ._Date Issued �, ��� _ _Area <br /> trout Inspection By Date Final Inspection By Date <br /> estruchon Inspection By Owe <br /> COMMENTS f CONDITIONS <br /> FAC# <br /> OUNTING ONLY AID# <br />' PE CODES FEE INFO AMOUNT REMITTED) I CHEC ASH RECEIVED BY DATE PERMRISERVICE�REQUEST NUMBER INVOICE <br />,)NIT IV-6/1/99/sign bkpg/MI <br /> Z0 39Cd 800-13 H13I3 £EbE89b60Z 5Z 91 000ZIOZIt0 <br />