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— --��-' ly••fir cu7vDt7.o4�y F1F (F1 FLUUH PAGE 02 <br /> tet. <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 99202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1 <br /> ApplIcatlon is hereby made to San Joaquin County for a permh 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 Stardards of San Joaquin County Public Health Services, Environmental Health Division. <br /> WELL Location I�fr /V• 0 1r+ao(c Cross Street � �City. —/ a,?` Zipi� � pAssess#ots <br /> PROPERTY Owner G5RA f Address a S �fbo,ad,sl� City�d� Zip�52—ZPhonell <br /> C•57ContraUar,�c"¢44 �r-i{i?�S Address T�� �� � CityN(g,r'�7�te�–Zip`t`t�3LiclIYaS{�SphoneAl'(,4� �r3'��O Y <br /> Consultant!Sub Contracts Arima �t iTMa o+'Address 7--10 Pc- r . City S n Lir71 Phone – �• <br /> GIS Coordinates-X Y Township Range Sec0on <br /> WORK TO BE PERFORMED <br /> 13 NEW WELL 1 BORING(CPT,GEOPROBE,HYDROPUNCH, HAND-AUGER,OTHER-) AESTRUCTION(choose type below) II <br /> p SOIL BORING# XOVER-BORE <br /> a WELL# WRESSURE GROUT <br /> 'Other, <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ;$VONITORING HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?[]YES ONO WELL CASING DIA: <br /> a EXTRACTION p AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: O STEEL p-PVC Q OTHER; <br /> IJ VAPOR. 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIIE TYPE TO BE USED: GAUGERS DHOSE t <br /> [}AIR SPARGE p PUSH POINT GROUT SEAL PUMPED p Yes Q No (NOTE, MAXIMUM FREE-FALL.DEPTH IS 30) e <br /> p SOIL BORING 0 HAND AUGER APPROX.BORING DEPTH p BOLTED TRAFFIC BOX or B STOVE PIPE <br /> 5 OTHER- []OTHER CONDUCTOR CASING PROPOSED? (If YES, list spsciflcations here)' <br /> , <br /> COMMENTS: <br /> { <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> 1 hereby certify mat 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 Rogulations of the San Joaquin County. Homeowner or licensed Agent's signature certifies the following: '7 certify thefin the perfommnce of the work <br /> for which this permit is issued,1 shall not employ persons subject to WORKERS'COMPENSATION taws of califomia." Contractor's hiring or Sub- <br /> contracting signature certifies the following:-1 certify that In the pefformanoe of the work for which this pennit;s Issued, ;shell empfoy persons subject to <br /> WORKERS'COMPENSA rION Laws of Califomm" <br /> CALL THE.. W ;IV,I OR 48 WIN ADVALNCE<KORA, L;REQUIRED'INSPgC!'IONS. <br /> Signed x Title/Company <br /> Print Name1act� Date y .w!Qi tiw,• yr. rk.• <br /> DEPARTMENT USE ONLY �1 <br /> Application Accepted By Date Issue CL at/ Area <br /> Grout inspection By Date Final Inspection By Data <br /> Destruction Inspection By Dale <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY; AID# <br /> t, <br /> PE COZIES FEE INFO AMOUNT REMITTED CHECK 9 RECD BY DATE PERMIT I SERVICE REQUEST#- INVOICE <br /> 3.6-0 60 . o0 j 3Ge,) OLSL7.92 <br /> 1/18/2000 <br /> i <br />