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8-25-1999 11 : 10AM FRO1,1 P. 11 <br /> WELL PERMIT APPLICATION FORM 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 /> . AsessofSs <br /> WELL Location - Il) ti.ure.6 eYpCzi <br /> p 102- Parcel#N " nu Fa <br /> PROPERTY Owner Iik Address305 N. el AT/ajo 5-7L_City ZpJ5207-Phone# 1�PL1 `154-99 <br /> 34-99 <br /> 0 <br /> C-57 Contractor &!G tsi-1f�t /..YM+17�i�M/4ddress /ya7 S SOt�S7• City it � �Zip�l.idf 363B�Phoned SI(� �3�-`IJ�S <br /> Consultant/Sub Contractor I✓E(rA"IfI 61(1, Address 5riS MrM_1#yAu/�S�ICity 64140cLidt Phone# y .55?OGgO <br /> GIS Coordinates:X , Y .Township Range Section <br /> — —. . ...._ ._..._.__._ <br /> WORK TO BE PERFORMED `/ <br /> 0 NEW WELL/BORING(CPT, GEOPROBE. HYORI�O-,Py N_C��H. HAND-AUGER,OTHER-) .&DESTRUCTION(choose type helow) <br /> SOIL BORING# 1-4_ OWT_ ' p OVERBORE <br /> 0 WELL# IkPRESSURE GROUT <br /> 'Other: <br /> COMMENTS. <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE 3-1"c4 MULTIPLE CASINGS?U YES 0 NO WELL CASING DIA:_ <br /> p EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: p STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS I]HOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED' 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING p HAND AUGER APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or p STOVE PIPE <br /> 0 OTHER—_o OTHER66gPa76� CONDUCTOR CASING PROPOSED? (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,l 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 ror which this permit s;issued, I shall employ persons subject to <br /> WORKERS'COMPENSATION Laws of California.' <br /> iE PL ANT, UST CALL 48 HRS IN ADVANCC7E FOR ALL REQUIRED INSPECTIONS. <br /> Signed x ! Title 1 h?VI ACJ ALw 4G evt Oate lam/y <br /> SEE SITE MAP N UNIT IV WORK PLAN DATED p <br /> r DEPARTMENT USE ONLY <br /> Application Accepted Bate Issued 1/15-1 g Area NOy <br /> Grout Inspection By Date1 5F 14q"inal Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/nil NS: t S f-42 <br /> FACS <br /> ACCOUNTING ONLY. AIO# 1 <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#lCASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> z p l 89 .00 <br /> C-57 LICENSED CONTRACTOR MUST SIGN LIC RKE ' CONIPENSATION DECLARATION <br /> UNIT IV - 6/23/99 /sign bkpg/MI .,J <br />