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WELL PERMIT APPLICATION .e-u UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION ("PHS EHD")SEp <br /> 304 E. Weber, Third Floor, Stockton, CA., 3 2)O%f� �2 7999 <br /> (209) 468-3450 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED - `�f,' •-_�Lr�' <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 Tdle,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br /> S•L/NCt7Il1J Ci i Assessor's <br /> WELL Location IZ95 �. else✓- A�l� Cross Street ry s/' � Zip <br /> �lS�z�2 Parcel# <br /> 1y C / � p 0. Z 30 C L d ��'e 3o <br /> PROPERTY Owner f.�it'4�l 11A�Nt�ru2 ba1�'�Address_r���x City t7 1 Zip q5 � Phone# Z(� �34-'jZ: <br /> —T! r <br /> 0-57 Contractor M1At9ced 6Efle�w''y�� '"Address 41305-d wlike� id' -/ City �Lk� Zip�Lic#6 O2Z/�hone V9 4x07- � <br /> Consultant/Sub CoritractorAd#lr, 4W§J01PEW.Address *V5W-1't'JxWLr �• City LimA6C4?2-7Phone# 42-164& <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> [] NEW WELL/BORING (CPTGEOPROBE;HYDROPUNCH• HAND-AUGER. OTHER-) DESTRUCTION(choose type below) <br /> kaG# OVER-BORE <br /> Q WELL T Q PRESSURE GROUT <br /> -Other. 13er^fAJ��S 01 11 b,r qr�N ed �'SU 9, �,(Au!/ &,J'hw+•fa ct4-�t- Slarr!l r-%i')( . <br /> CCMMENTS: A µ!1 /l be kr1 I1 Zcd. - <br /> YPE OF WELL CONST RUCTION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING Q HOLLOW STEM DIA.OF BOREHOLE ;C MULTIPLE CASINGS?0 YES Q NO WELL CASING DIA: <br /> –/- <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS III,4 TYPE OF CASING: Q STEEL a PVC 0 OTHER <br /> VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL > t *L- TREMIE TYPE TO BE USED: 0 AUGERS 'SE <br /> AIR SPARGE r'USH POINT GROUT SEAL PUMPED: Yes_p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> ,(SOIL BORING Q HAND AUGER APPROX. BORING DEPTH IS iijcr ba4 •a BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> OTHER: CONDUCTOR CASING PROPOSED? (if YES. list specifications here): <br /> COMMENTS' 0 well Con) SIT we w, i Q rc ri 7- ba e%;y!I 1b so V,� Vo-'/t-de tJ 1bt-AP �1 t <br /> Lel"&JT <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS! <br /> I hereby certify that I have prepared this application ano 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 licensea 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 COMPENSATION Laws of Califomia." 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 /> WORKMAN'S COMPENSATION Laws of Califomia.' <br /> THE APPLICANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed x1-r;4 /• ecl e Date Q <br /> SEE SITE MAP IN UNIT IV WORK PLAN. DATED 081zz 081z `I <br /> � DEPARTMENT USE ONLY c <br /> Application Accepted By Date Issued ( Area <br /> Grout Inspection By Date Final Inspection By Date� <br /> Destruction Inspection By Date 1 <br /> COMMENTS/CONDITIONS: 6�y �,.,P,c Sra•..-p Q/LOp f f--w UST LD� L _ <br /> lJ U I <br /> FAC# <br /> ACCOUNTING ONLY: AID# <br /> .�E CODES FEE INFO AMOUNT REMITTED CHECIr(-�CASH I RECEIVED BY DATE I PERMITISERVICE REQUEST NUMBER INVOICE <br /> =-� t /Z7 / Z I 14-6-' <br /> UNrT IV-5/99/MI <br />