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81 14 45 2694683433 nnrr- rA1 <br /> FIFTH FLOOR PAGE 62 <br /> + r <br /> , <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 , 95202 <br /> (209) 468-3450 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Appf=Uon is hereby e+nade to San Joaquin County for a permit to constrmct.anwor Install the work dtrsrrrbed This application+s made in complsance with <br /> San Joaquin County Development Title Chapter 9-1115 3 and the StandarUs of San Joaquin County Public H"Ith Serncgs Ern,runrnental Health D+visron <br /> 6 f 0(JI /r_� -�(� p ,, Assessors <br /> WELL Locatlar-_� �C11L _px_J t ate.' Cross 5trett_{(� �Ave-rCttys�lilt tti zQ Parcer>rba7-464-18 <br /> ?RQFt:FC7Y Owner CL�r G'� �Address `�Z� I'U �1 Llc7 COY zi0 S honed <br /> C-57 Contractor � s ry - <br /> ��`I % Address 1ZC� GV ,M{.x Zip ass$ L.-O $ Phanep(ALS)3 J3-S ff� <br /> ,,,-L / <br /> Consultant/Sub Coniractoria. t�o� 111.t�t S+�AI Adaress7-�� +p 0`►yS 1i. A La <br /> CrtyS(_) t0. c# Phonert(1!1)c sJts!� <br /> GIS Caordrtl3teS X Y Township Range Secuon <br /> WCRK TO BE PERFORMED <br /> g�NEVV WELL 1 BORING(CPT GEOPROGE HYOROPUNCH HANp_AIJGER, OTHER-) Q CESTRUCTION(choose type oelow) <br /> I3 SOIL BORING it Q OVER-$ORE <br />-Qthnr g<NELL# 12 PRESSURE GROUT <br /> CCMMENTS <br /> TYPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br /> I iTORING gFIOLLOW STEM i]t►l OF 801ZENOEE MULTIPLE CASINGS-a YES NO WELL CASING DIA 2 <br /> 91ACTION ❑AIR HAMMER/DRIVEN CASING TNICKNESSSe�%-X40 TYPE OF CASING 0 5TEEL e;-'VC t3 OTHER <br /> I VAPOR l7 MUD ROTARY DEPTH OF GROUT SEA"— 6ot TREMIE TYPE TO BE USED R/UGERS QHOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SERI.PUMPED glfes Q No (NOTE. MAXIMUM FREE-FALL DEPTH IS 30') <br /> Q.SOIL SORING Q HAND AUGER APPROX_13ORING DEPTH '" % t Y�OLTED TRAFFIC SOX or II STOVE PIPE <br /> 3 CTHER CONDUCTOR CASING PROPOSED7 NO (if Y� list specifica6onS here) <br /> CQMMENTS <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS! <br /> hereby cFrtify that I have preoared this apptfcatron and that the work wdl be done in accordance with San Joaquin County Ordinances State Laws and Rules <br /> tnd Regulations of the San Joaquin County. Horneownef of trcensed agents signature cert,fes the followrrtg_ 1,1 certify rhatin rho performance of the work <br /> or which this permit is issued I Shaff not emproy persons subject to WORKMAN S COMPENSA77ON Laws of Calrlomja" Contractor s hrnnq or suq- <br /> Cntfactrng Srgn=re ceOttigS the following- '1 Certify That in tee porfarmanco of Mo work for which Mrs parmt rs rssutzd I shalt omploy porsons subtect to <br /> vORKMaAN S COMPENSATION LawS of California ` <br /> TIi1` ICANT MUST CALLA$FIRS IN ADVANCE FOR ALL REQUIREDINSPECTIONS <br />,Igned x Trtf�r '�/l�Ze �✓f�r~y�d <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED <br /> [DEPARTMENT USE ONLY <br /> pptic3tion Accepted By {{ ��n r-jam -- _ hate Issued -•• 1� {�e -_ area <br /> rout Inspection By Date Final Inspection By / Date <br /> estructlan Inspection By pate <br /> OMMENTS/CONDITIONS <br /> A NTING ONLY- AIDER FACS <br />�E COOES FEE INFO AMOUNT REMITTER CHECKVJCASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE <br />,�c� <br />