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11-24-1999 8:39AM FROM P_ 2 <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> M!9 <br /> RONMENTAL HEALTH DIVISION ("PHS-EHD") <br /> E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3450 <br /> NON-REFUNOASLE 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 Health Division, <br /> "� <br /> 1-- Assessor's <br /> WELL Location 1130 /1- /ICIIA 51" Cross StreetLOV� /6JC— City�nTLP Parcelo L-1.8 <br /> PROPERTY Owner r Js fF (vL� I�Aadress 3ggo Yesen i'1C-hve-- City re 2ipgS3S0 Phone#Z�-SSS <br /> C-57 Contractor FIS GnVI/OAnC/Vh►_Address3°lal Atrf'l�S I�6ACC CityS�1C Zip�_Licst PhoneaxZo�1 '77L '35?0 <br /> a J, 3140, cold Cwn/P/,. ka 916 -9s3 q rte; <br /> onsultan / <br /> Sub Contractor 1p`� #4 500-AoV�S Address S 01 t C- 1(-6 City 0^_Licl Phones <br /> GIS Coordinates:X ,Y Township Range Section <br /> WORK TO BE PERFORMED <br /> NEW WELL 1 ORIN CPT GEOPROSE. HYDROPUNCH.HAND-AUGER, OTHER-) Q DESTRUCTION(choose type below) <br /> ,kSOIL BORING# &h -k Q OVER-BORE <br /> (I WELL z G PRESSURE GROUT <br /> 'Other: <br /> CC�.MMENTS: <br /> TYPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br /> Q MONITORING Q HOLLOW STEM OLA.OF BOREHOLE Z" MULTIPLE CASINGS?Q YES 13 NO WELL CASING DIA: N�� <br /> a EXTRACTION Q AIR HAMMERIDRIVEN CASING THICKNESS JV It TYPE OF CASING- Q STEEL Q PVC Q OTHER: IVIA <br /> G VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL� LO 4 TREMIE TYPE TO BE USED: GAUGERS AHOSE <br /> G AIR SPARGE PUSH POINT GROUT SEAL PUMPED: {1 Yes , No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> �' L / <br /> X301L BORING 0 HANG AUGER APPROX.BORING DEPTH O BOLTED TRAFFIC BOX or Q STOVE PIPEQ <br /> Q OTHER: CONDUCTOR CASING PROPOSED? N (if YEs,list specifications here): <br /> COMMENTS: <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: "1 certify that in the performance of the work <br /> for which this permit Is issued,1 shall not employ persons subject to WORKMAN'S COMPENSATION Laws of California." Contractor's hiring or sub- <br /> contracting signature certifies the following: '1 certify that in the performance of the work for which this permit is issued, I shall employ persons subject to <br /> WORKMAN'S COMPENSATION Laws of Califomia_' <br /> T APPLICANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. �y <br /> Signed x U Title <br /> l` Aa ef k��r�nnP�V�I Date <br /> U'`V l G� <br /> SEE SITE MAPYINUNIT IV�W R PLAN DATED <br /> AARR/TM�E�NT USE ONLY / 7 j <br /> Application Accepted Sy. <br /> rl /' 1 l�'�7 Date Issued f Area LxJ <br /> Grout Inspection 8y Date Final inspection By Date <br /> Destruction inspection 8y Date <br /> COMMENTS I CONDITIO NS-IL a <br /> FAC# <br /> ACCOUNTING ONLY: AIDC <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#JCASH REC>rIV D By DATE PERMITISERVICE REQUEST NUMBER INVOICE <br /> 1,o jZ,o 00 34- <br />