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WELL PERMIT APPLICATION FORM UNIT IVto IP <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES FILL GU <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) WA41 <br /> „'/ 6304 E. Weber, Third Floor, Stockton, CA., 95202r <br /> (209) 468-3449 uZ0 0°a <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1 "-zby,^�,"y�� <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 JDaouin County Develooment Title.Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> Assessor's <br /> WELL Location •1217 ELW I.r6Oof Cross Streer 9�t p <br /> lty S%o�klon Zip 152P�] ParceH! <br /> PROPERTY Owner - 6-.�r.C'!7D/1/ Address Z/Z� wtiW�� City S IVIG ilnn Zip Phone# yb8 Se 58 <br /> WEST Noe /rut r S1 R4%c1J0 <br /> C-57 Contractor Or, Mr, Address-123 J f+7-5Prc./n Cdyf QrOn.,G. Zip 57 ZLic#SS4979Phone# q� 72 �`. <br /> Consultant l Sub Contractor—&.6Address 44o5 IV, tv, )5" V'City S7scKi�n Lic#65Jr Zz 7Phone# 7n5 U67/oo I( <br /> GIS Coordinates:X ,Y Township IN Range F Section. _ <br /> WORK TO BE PERFORMED <br /> NEW WELL/BORING(CPT,GEOPROBE, HYDROPUNCH,HAND-AUGER, OTHER-) 0 DESTRUCTION(choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE <br /> 'Other: <br /> �R'MIELL# M V.)-'*' 0 PRESSURE GROUT <br /> //�� <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE 117 i^C Pt MULTIPLE CASINGS?RYES ONO WELL CASING DIA: Zl,ncl4 <br /> 0 EXTRACTION AIR HAMMER/DRIVEN CASING THICKNESSS`µ T 1e <br /> O �TYPE OF CASING: 0 STEEL hrPVC 0 OTHER: <br /> p VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL Z FE £ F TREMIE TYPE TO BE USED: GERS SE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED:>J�Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH Is 30') <br /> 0 SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH ' S ;MOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER:_O OTHER CONDUCTOR CASING PROPOSED? ( 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: "I certify that in the performance ofihe 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: "I certify that in the performance of the work for which this permit is issued, /shall employ persons subject to <br /> WORKERS'COMPENSATION Laws of California." <br /> T APPLIC�N`T MUST <br /> CALL 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed �� �)!/— Title-Li- C-7 ce&1195d Date 5 1q-9 0 <br /> Add.+. 2.4-0o <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED: OIOI PEC( MApr 9qr <br /> DEPARTMENT USE ONLY (� <br /> Application Accepted By Date Issued (o- I -O Area Q 6 <br /> Grout Inspection By Date Final Inspection By ETE Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# PArt <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> SZ 6-+�o0 23 o p <br /> C-57 LICENSED CONTRACTOR MUST SIGN LICENSE &WORKERS' COMPENSATION DECLARATION <br /> JNIT IV- 6/23/99/sign bkpg/MI <br />