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1 ' <br /> WELL PERMIT APPLICATION F M UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES n <br /> ENVIRONMENTAL HEALTH DIVISION ("PHS-EHD") <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 AUG 2 3 2000 <br /> (209) 468-3450 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> r <br /> Application is hereby made to San Joaquin lCounty 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 96-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health.Division. <br /> i Q ty ��� <br /> Assessor9 <br /> WELL Location $6 1 OOICI ad Cross Street V Ci 1'1 Z' �7 Parcel# J UI ��- l <br /> PROPERTYOwner U aT'1c(A Address I l�� 88e l :y C G v]JJG1 <br /> /f r f , �1'_ -_Ci ly Zip�Phone#t7oj 4�1ao3 I <br /> C-57 Contractor ��J 0 Address VM ✓" • 1317-!/G City 5 t. Zip O Lie#QVA2 Phone# 6?lQ6 <br /> Consultant 1 Sub Contractor I` ll^5 AddressyC057kif-fro, "I/ City-;blOG Lisp 6g0 Phone;(DIV� VOc <br /> y <br /> GtS Coordinates:X �Y Township : Range Section <br /> a <br /> WORK TO BE PERFORMED <br /> )(NEW WELL/BORING(CPT.GEOPROBE,HYDROPUNCH, HAND-AUGER.OTHER-) a DES T RUCTION (choose type below) <br /> BORING <br /> a WELL = PRESSURE GROUT <br /> -Other: ' I <br /> t <br /> COMMENTS: <br /> TYRE OF WELL CONST RUCTION TYPE. CONSTRUCTION SPECIFICATIONS <br /> MONITORING HOLLOW S I Em ' DIA. OF BOREHOLE � MULTIPLE CASINGS?o YES )(NO WELL CASING DSA: <br /> i <br /> EXTRACTION AIR HAMMERIDRIVEN CASING THICKNESSTYPE,OF CASING: a STEEL Q PVC a OTHER:_: <br /> VAPOR MUD ROTARY DEPTH OF GROUT SEA: � T rREMIE TYPE TO BE USED: Q AUGERSfOSE <br /> 3 ,IR SPARGE 3kPUSH POINT GROUT SEAL PUMPED: Q Yes nKc- (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING [{HAND AUGER APPROX. BORING DEPTH 14 S` _a BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER: •i -CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> COMMENTS: d <br /> ;i <br /> NOTE: OFFSITE(BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS? <br /> hereby certify that I have prepared this application and that the worx will be done in accofdance with San Joaquin County Ordinances, State Laws. and Rues <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 WORKMAN'S COMPENSA77ON laws of Califomia." Contractor's hiring or sub- <br /> , :attracting signature certifies the following: 'I certify that in the performance of the work for which this permit is issued. I snail employ persons subject to <br /> WORKMAN'S COMPENSATION Laws of Califomia.' <br /> THEAPPLICANT <br /> MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed x, Title G / Date 9 7-00 <br /> SEE SITE MAP IN I UNIT IV WORK PLAN. DATEDv <br /> PARTMENT USE ONLY f� <br /> AopElCation Accepted By C. Date issued <br /> 0 `�611?60o " Area <br /> Grout Inspection By Date aminal Inspection By Date <br /> Destruction Insaecfion By Date <br /> COMMENTS I CONDITIONS: <br /> FAC-- l <br /> ACCOUNTING ONLY: AID# ip <br /> PE CODES FEE INFO AMOUNT REMM=rED CHECK#ICASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE <br /> io 11 _ d 4 Q®- : <br /> UNIT IV-5/99/Mr <br />