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- - UNIT <br /> WELL PERMIT APPLICATION FORM <br /> SAN JOAQUiN COUNTY PUBLIC HEALTH SERVICES {. <br /> ENVIRONMENTAL HEALTH DIVISION ("PHS-EHD") Y i <br /> Stockton, CA., 95202 <br /> 304 E. Weber, Third Floor, <br /> (209) 468-3450 E 13 3 3 C �ta ,� • !� <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISS +I pA J <br /> [r A 01SErIct <br /> ' SSff d iIrv1�]� <br /> r r aridlo ir`nsfajl t; work described. Thtapplicdtion rs made in compliance witApplication is hereby made to San Joaquin C my for a peruin Count Public Health Services,Environmental Health�{�iv n. <br /> Assessor's 6 f �v �rDS <br /> San Joaquin County Development Title,Chapter 9 1115.3 and the Standards k of Sad aq y 9510 3 parcel# <br /> W�`{ Cross Street V City S i C C K rt d N zip <br /> -L51 <br /> Loc tion 1333hone# `'r 3 <br /> SiCa C CA City C Zip <br /> PROPERTY Owner N �> 1 f Address 9�.''S <br /> v �EGG �Ik'RTtNE r 9�k553Lic#E564OlPhone# 313— '1200 <br /> C57Contractor_U1ii�LiNG�TESTtNCrAddress 9�O t}E;WI= COAD city p 1C�1 <br /> +N A IG t 5V Address �� t= I. <br /> t OT4 t. City Lic#X515 0 Phone# Ri - _4 <br /> Consultant 1 Sub Contractor V Section <br /> i Taw,^.;hip Range.�- <br /> I GlS Coordinates:X <br /> I - <br /> WORK TO BE PERFORMED <br /> l]DESTRUCTION(choose type below) <br /> NEW WELL/BORING(CPT GEOPROBE,HYDROPUNCH,HAND AUGER,OTHER-) 13 OVER-BORE <br /> SOIL BORING# GPT- I]PRESSURE GROUT <br /> la WELL# <br /> .Other: <br /> COMMENTS: - <br /> TYPE�tt CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING . []HOLLOW STEM DIA.OF BOREHOLE i1��MULTIPLE CASINGS?0 YES NO WELL CASIN DI N�A <br /> p EXTRACTION Q AIR riAIVIMERIDRIVEN CASING THICKNESS Nom-=TYPE OF CASING: d STEEL Q PV HOSE <br /> 17 VAPOR []MUD ROTARY DEPTH OF GROUT SEALI O"r 1"1:5 f TREMIE TYPE TO BE USED: 0 AUG t <br /> POINT �Gt�T') GROUT SEAL PUMPED: 1 Yes p No (NOTE: MAXIMUM FREE-FALL E IS 30'} <br /> PUSH <br /> a AIR SPARGEt 1 S ll BOLTED TRAFFIC BOX or S7 PE <br />' SOIL BORING p HAND AUGER APPROX. BORING DEPTH N <br /> �a (if YES,list specifications here): <br /> CONDUCTOR CASING PROPOSED? <br />{ 0 OTHER: , <br /> o w(t,I. �� oN t` �ta��au�iaS Nl;alt r'►W �k (ta,TEtiD OF f <br />!r COMMENTS: THt5 0 E-ATIOR CITY CF S ot.INTOR WBAMD 1 NCTtOAG.t3M�NT� <br /> CENSER t_A�Nt= 0� GVIATITK-R WAY. <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS ENCROACHMENT IPERM1TS1 ances,State Laws and Rules <br /> hereby certify that I have ...............prepared this application and that the work will agents <br /> done in nccog. „ y performance <br /> ns subject to WORKMAN'S COMPENSATION Laws of California." Contractor's hiring or sub- <br /> and Regulations of the San Joaquin County. Homeowner oor licensed agent's signature certifies the followin 1 certrf I shall a ploy persons subject to for which this permit is issued,l shall not employ Pers 1 <br /> contracting signature cerlifes the following: "!certify that in the performance of the work for which this permit is issued, <br /> WORKMAN' COMPENSATION Laws of California." <br /> APPLICANT ST CA L 8 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Date-I h� . <br /> TitleA" <br /> . <br /> Signed x <br /> SEE SITE 1 UNIT IV WORK PLAN: DATED/ �Mft t' tT c tt R <br /> EPARTMEN USE ONLY Area <br /> Issued J�1 <br /> Application Accepted Byj" Date Z Z <br /> Date <br /> Final inspection By <br /> Grout Inspection By ate <br /> Destruction Inspection B i S to <br /> COMMENTS CONDITIONS: <br /> rf i$ <br /> ST � � �� ' ' ! <br /> i FAC# <br /> ACCOUNTING NLY: AID# <br /> C D BY DATE PERMttTlSERVICE REQUEST NUMBER INVOICE <br /> PE CODES FEE INFO AMOUNT REMITTED GHEGK#!CASH r <br /> c' t NIT IV-6/1/99/sign bkpg/MI � <br />