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P. 3 <br /> WELL PERMIT APPLICATION FORM \ J UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEAL 'EIV �/ E <br /> ENVIRONMENTAL.HEALTH DIVISIO ( FSS-EHD) <br /> 304 E.Weber, Third Floor, Stockton, CA., 9-VV 2 2 1999 <br /> (209)4684449 <br /> Cl�,1���q(� MENTAL HEALTH <br /> NON-RERUNOABLE PERMIT EXPIRES 1 YEAR FROI#'DATLtISII . c+cn\!ICES <br /> AppW§Wn as hereby made to San Joaquin County=for*went to construct and/or antaii the work de 'd ma0e in compliance with <br /> San Joaquin County Development Title,Chapter 9-111&$and the Standards of San Joaquin County Public Health SeMoss.Eavironmerttal Health Division. <br /> AftftW <br /> WELL Location t(Y (" n t-b i� s rl gross Street VVIL H P �City ' 04TV A/zip 9pS�z—Pa s <br /> PROPERTY owner L1�LONTIc- Addrass:Fc 1`r3 S}!� City SG Zip?4i1l_Ptwn�l'Y/y Z4}35Lo <br /> ARN.$. IGL`w tC.+1 <br /> C-P contractor�y�aaress`I.SV Bock' citAt+4RT�.J; ;yyp99S5 Lid(!$�516 nerhe#W O I3 5VVV <br /> Consultant I Sub Contractors C"147,1N tet ILL- AddnswFC%Q)L 126$1 Ck9-5 r"W1'�'t UC# Phone# ZY I Z4M <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE 1'11RFORMED <br /> KNEW WELL/BORINGCPT EOPROBQ HYDRO CH,KAN ,OTHER-) Q DESTRUCTION(choose type below) <br /> 7` SOIL BORING# � 6 .'{�j Q OVER-BORE <br /> ELL# Q PRESSURE GROUT <br /> 'Other: <br /> COMMENTS: <br /> INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING Q HOLLOW STEM OW OF BOREHOLE MULTIPLE CASINGS?Q YES Q NO WELL CASING DIA:_ <br /> 0 EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS QHOSE <br /> 0 AIR SPARGE Q PUSH POINT GROUT SEAL PUMPED. 0 Yes Q No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER: 0 OTHER CONDUCTOR CASING PROPOSED? (if YES,list speciflwtions here): <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby oMty that i have prepared this appticallion 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:h certtly that in the performance of the work <br /> for wdd t tots permit is Issued,/shall not employ parsons subjent to WORKERS'COMPENSATION Laws of California." Conbactor•s hiring or sub- <br /> contracting signature certifies the following: 9 cerdb'that in the performance of the work for which this permit Is issued,I shell employ persons subject to <br /> WORKERS'COMPENSA TION Lows of California." <br /> THE gPPLICANT:MUSTCAL! 48 WORKING.HRP IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed x Title Date <br /> SEE SITE MAP ��IN\�U��NpIT IV WORK PLAN DATED: <br /> Application Accepted By (UIt'W,OItA/t(.OW+1 DEPARTMENT USE ONLY <br /> Date Issued I(' L'"1`-I 1 Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITION L, t- :fftI1AA),V CAZ.O%s' '*J $l✓Y)N1 <br /> ACCOUNTING ONLY: AID# <br /> PE CODES I FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST it INVOICE <br /> 901 IM AlialkiL.J. 5r <br /> C-57 LICENSED CONTRACI'OR.MUST.SIGW INCENSE&WORItERS'COMPENSATION DECLARATION <br /> VMT IV-6/23/99/sign bkpg/MI <br /> r <br />