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WELL PERMIT APPLICATION F�RM 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,Environ a sormental <br /> Health Division. <br /> WELLLocation 4)-3 M- Madisoo 51­ Cross Street fy.Mew City 5�'o(K1 Ott Zip47j'61 Parcel# <br /> PROPERTY OwnerAulo TAV'511101.'IfIs Address 454% fre'14'r PI•^'v Dr- City 57_LKli \ Zip95?I1 Phone#N73'$4aC <br /> 11clMoxrt! (,• Fx Viroe rx'xAddress KOCSN. w:lSah 4UcrY City 1 N Zipgslo6 Lic-610117 Phone#'(67'100(; <br /> C-57 Contractor r , <br /> Consultant/Sub Contractor Address City Lic# Phone# <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED <br /> R NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> &SOIL BORING# IjP' 6 7e 9 1 0 OVER-BORE <br /> 0 WELL# 0 PRESSURE GROUT <br /> 'Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLES MULTIPLE CASINGS?0 YES $ NO WELL CASING DIA: <br /> D EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS VIA TYPE OF CASING: D STEEL 0 PVC D OTHER: <br /> 0 VAPOR D MUD ROTARY DEPTH OF GROUT SEAL 7'. P, TREMIE TYPE TO BE USED: 0 AUGERS DHOSE <br /> D AIR SPARGE &PUSH POINT GROUT SEAL PUMPED: 0 Yes g No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> &SOIL BORING 0 HAND AUGER APPROX.BORING DEPTH 20 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER:_O OTHER CONDUCTOR CASING PROPOSED? IV U (if YES,list specifications here): <br /> COMMENTS: <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: "1 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 or sub- <br /> -contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to <br /> WORKERS'COMPENSATION Laws of California." <br /> CALL THE UNIT <br /> � IV/INSPECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed xx jt� %t /X, A Title/Company /}c)VeH(+c� �•e �NNirogWi'H �a ( <br /> ib� rh �1 19 '00 <br /> Print Name Kevi Date <br /> N N 14 �' <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED: <br /> t, DEPARTMENT USE ONLY <br /> Application Accepted By Date Issued UL1-0 Area <br /> Grout Inspection By Date i - nal Inspection By Date <br /> Destruction Inspection By Date r <br /> COMNfENTSICONDITIONS: Uk ar-- O r T1 <br /> S i JviM9- - ''( S 0 <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED 7CHECK REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> Zi C) Koo X 3 6 M 1Ao6 (0 3-0 <br /> 1/18/2000 <br />