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WELL PERMIT APPLICATION r-OR:N; ,,,--� UNIT IV <br /> SAP} JOAQUIN COUNTY PUBLIC HEALTH SERVICES �4" <br /> ENVIRONMENTAL HEALTH DIVISION ("PHS EHD"U3EP 0 . t ;� <br /> 304 E. Weber, Third Floor, Stockton, CA. 55625 ?,/Nil 2 999 <br /> (209) 468-3450 TA <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 desc.-ibed. This application is made in compliance with <br /> San Joaquin County Development Title, Chapter 9-1115.3 and the Staneards of San Joaquin County Public Health Services, Environmental Health Division. <br /> J, 5.11�1C0% Assessor's <br /> 'WELL Location S ( e I6",/'/ ��/' \ Cross Street City s%tj/C�tiC/vJ Zip �l S�l�Z Parcet# <br /> PROPERTY Owner Mr.�niC4 ` i4/44�i l��ClAddress f•��X Z b�O City L�ai1 Zip gSzj/ Phone# Z� 3'3¢'/Z: <br /> r <br /> C-57 Contractor �VIj�iCea6e0 UJ i44 Triciress 4D05 (/•�VI,'�� W - City J�Lk '_ip Li 6 Oul�hOne <br /> Consultant I Sub C�,,tractorA8VrNc:l(6ii fV§wJJI1fW.Address 4Q.5/1 -;111Sb ) City S7t&k* 1 Lim iCCZ2 7 Phone,: 02-101(r <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> NEW WELL/BORING ( CPT GEOPROBE,'HYDROPUNCH, HAND-AUGER. OTHER-) STRUCTION (choose type below) <br /> G# 0 OVER-BORE <br /> 0 WELL# qq PRESSURE GROUT <br /> -other. 66r^fAJS „11 if bE a►r4o t'd k5 SUY �_ G(AC <br /> COMMENTS: /4T) f it'll"►l i E- ull /l bz Lkh II'Zcd- . <br /> TYPE Or WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICA T IONS <br /> MONITORING 0 HOLLOW STEM DIA, OF BOREHOLE 'i 'Ch MULTIPLE CASINGS? 0 YES 0 NO WELL CASING DIA: <br /> 9 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS JV A4 TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL #o'14L 7REMIE TYPE TO BE USED: 0 AUGERS = <br /> ] AIR SPARGE - r'USH POINT GROUT SEAL PUMPED: 0 Yes_p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> OIL BORING 0 HAND AUGER APPROX. BORING DEPTH WS1 D BOLTED RAF=1C BOX or 0 STOVE PIPE <br /> OTHER: CONDUCTOR CASING PROPOSED'?— if YES. lir specifications here): <br /> COMMENTS' /L O Well CoAJ S-froclfl ►•-1 ; orei'ir &r'1;N;g5 f0 �2l� t'.�i" A✓r <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> ' nereby ceniiv that I have prepared this application and ;oat the worx will tie done in accorcance with San Joaquin Counry Orcinances, State Laws, and Ruies <br /> and Regulations of the San Joaquin County. Homeowner or licensee agent's signature certifies the following: "1 certify that in the performance of the work <br /> for which this permit is issued.1 shall not employ persons subject to WORKMAN'S COMPENSATION Laws of California." 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 sna/l 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 x �G►1ti I- -�`�Ci Cvl' 4 '7 m L i rtIe �+�ec�C�'i�S`� Date ah <br /> SEE SITE MAP IN UNIT IV WORK PLAN. DATED r� Z Ael <br /> DEPARTMENT USE ONLY Cc, <br /> Apolication Accepted By 1�M��t Date Issued 7I�l / Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date / <br /> COMMENTS[CONDITIONS: 6�y �fpQr c 2� e.k pJLo,.J S/�� ,4-, / U.ST LDI� S <br /> FAC# <br /> {�I ACCOUNTING ONLY: AID# <br /> PE CODES I FEE INFO I AMOUNT REMITTED CHECI�/CASH I RECEIVED BY DATE I PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> is <br /> i <br /> Z7 <br /> UNIT IV-5/99 /MI <br />