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WELL PERMIT APPLICATION FAM 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) 468-3449 <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/or install 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, Environmental Health Division. <br /> sTor-K-roen C.A- vif-sr Logto Assessor's <br /> WELL Location 3230 WZs LA,,i ; Cross Street L AlpinI- BVI-,City 5 T6c-KTorizip 95Lc,5 Parcel# <br /> PROPERTY Owner U.0N o <br /> Df I o I `n� —Address-?.Q. 8C7, 1/4J 7 City 5raLK 7o n Zip95Zc)1 Phone# Zo`t•`t tvS-3 Yz/ <br /> Z <br /> C-57 Contractor MikLh%ll (D (1��RiIIrAddress536o 4v�Tl� WOf}AU City((T�i OPr14io95k2bLic#(o7ZJe17Phone#9/b' 3�b Vb b rJ <br /> Consultant/Sub Contractor / <br /> A G Address /0 0 5 pi, wrr15o r, city s f oc.l(-fnn//Lic# %U 7 Phone# z o�l' Yb 7-/o n 6 <br /> GIS Coordinates:X Y ,Township 1;? Range 10 Section <br /> WORK TO BE PERFORMED <br /> )T1EW WELL/BORING(CPT, GEOPROBE, HYDRQPUNCH, HAND-AUGER,OTAitM- -1111 D DESTRUCTION(choose type below) <br /> SOIL BORING# F-7 0 OVER-BORE <br /> A'WELL# M W`) M oi-Z MW. RJD PRESSURE GROUT <br /> 'Other: _ <br /> 7 <br /> COMMENTS: �I <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> C�- <br /> ,r rr <br /> MONITORING HOLLOW STEM DIA. OF BOREHOLE $v MULTIPLE CASINGS?D YES D NO WELL CASING DIA: Z _) <br /> D EXTRACTION D AIR HAMMER/DRIVEN CASING THICKNESSS-A Ovit `/O TYPE OF CASING: D STEEL $ VC D OTHER: <br /> -- <br /> 0 VAPOR D MUD ROTARY DEPTH OF GROUT SEAL Yo VE 40- bS(- TREMIE TYPE TO BE USED: JOUGERS OHOSE <br /> O AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: ;Yes D No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING O HAND AUGER APPROX, BORING DEPTH 6S Fl;F aS(P;KBOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER:_0 OTHER CONDUCTOR CASING PROPOSED? u o ( if YES, list specifications here): <br /> 145F- <br /> COMMENTS: 5�iE- ARPfriQED W ('K Ar-) Dq-rE-Q O/ lf�88vAAy 2000 <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 o'r 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 x Title/Company N�V NL�p 7�'Fa�rt�rinn++�pn -� <br /> Print Name Date <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED: o I r,"3 zo•Q <br /> DEPARTMENT USE ONLY _ <br /> Application Accepted By �JGC�� Date Issued 5// c9/ ��� Area Q > <br /> r <br /> Grout Inspection By c c2 v� �i� /j1G '/ Date=iGFinal Inspection By Date <br /> Destruction Inspection By tee. ,Z,.,.0 Date -(-,--cc <br /> COMMENTS/CONDITIONS: 4 ('7 <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> ! 3 7 <br /> 1/18/2000 <br />