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wopy <br /> WELL PERMIT APfVCATION FORM <br /> �Vlllfu �� SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES D� <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 w,D� ��1 ✓/T, <br /> (209) 468-3449 (� <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/orinstall 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, EnvironmentalAssessorsHealth Division. <br /> WELL Location Zt03 Co NTitY Cl LA RLV D Cross Street V CgANV-LYNI City S-rcLtTO'N Zip GSLu A Parcel# 1230067-9 <br /> PROPERTY Owner,fIAp_y ocr cr-Tor. Zipg5ioq Phone#_(�a919S2-5215 <br /> R NCHO <br /> C-57 Contractor CASCADE Dwi LLZNC Address 3x32 OME-C C*RCL CitycoancfA, Zip95'Iy2Lic#117!5io Phone#1aLL&31-11119 <br /> ADlANCED GEO- <br /> Consultant/Sub Contractor Fn-••r:^"'^4i-;NrAL irVL Address 13,51 ,,NAW RD. City STOCIcreNLic# Phone# -1c<--f- <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED <br /> JR NEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER,OTHER-) 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE <br /> 5,WELL N-r ANSA My.l-\g o PRESSURE GROUT <br /> 'Other: <br /> COMMENTS 9-rFERENCE PtLPIN DATED 15 TANVA9Y 1G0-7. <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING ;d,HOLLOW STEM DIA.OF BOREHOLE $"MULTIPLE CASINGS?AYES ONO WELL CASING DIA: 2 ° <br /> n EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS c"envLe uo TYPE OF CASING: 0 STEEL H(PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL i'—teS xmG TREMIE TYPE TO BE USED: ,g AUGERS OHOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 2CYes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> o SOIL BORING o HAND AUGER APPROX. BORING DEPTH !Sa SAN A SO•'B.BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> n OTHER:_O OTHER CONDUCTOR CASING PROPOSED? WA (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 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: "I 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 California." <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed Title/Company< FF FN-r ST/An ED LCOENV'rQoNNFNTgL- <br /> Print Name acr-r(V 1 EE Date Z/ 231 0'-1 <br /> SEE SITE MAP IN UNIT IV ,WORK: PLAN DATED: <br /> Application Accepted By A L / DEPARTMENT USE ONLY <br /> YIL,, J�,i�,/.✓_�. � Date Issued 5-z/ �D Area ©`� <br /> Grout Inspection By Date __ __Final Inspection By + i'�ate <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> v 3 ZZ2T2� I OOSo 659' <br /> 1/18/2000 <br />