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i I <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 /> j (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 San <br /> Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Hepith Services, Environmental Health Division. <br /> l g� / �/ ?t5r � Assessors <br /> WELL Location /� 11 __!/ f Cross <br /> .[Street L( �'✓� C�'� CityZip ✓Parcel# p �7 Off,, y� <br /> PROPERTY Owner l/( rt, n r Address I Z6D J`0 �l City5 (/ Zipjf� L&&ViPhone#q/3 7 DY J K <br /> C-57 ContractorWM lVflZ /Mw A dress � //�r�I���n � (( Ci -. I ZZiip/p�,�� Zl..ic#'�71 -77 honelF <br /> Consultant / Sub Contractor Address'I y@AS )k & b01/.sl/fl CitVA Li ��/ Phone#_ <br /> GIS Coordinates: X., Y , Township Range Section <br /> WOR <br /> K TO BE PERFORMED <br /> NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') DESTRUCTION (choose type below) <br /> a SOIL BORING # a OVER-BORE <br /> 0 WELL # p PRESSURE GROUT <br /> 'Other: <br /> COMMENTS: <br /> VTYM OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS � �� <br /> ONITORING10LLOW STEM DIA. OF BOREHOLE_ MULTIPLE CASINGS? YES IJO WELL CASING DIA: <br /> a EXTRACTION QA1R HAMMER/DRIVEN CASING THICKNESS O. ®Z. TYPE OF CASING: 0 STEEL 015VC a OTHER: <br /> a VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL /S15j�TREMIE TYPE TO BE USED: 8&AGGERS OHOSE <br /> a AIR SPARGE PUSH POINT GROUT SEAL PUMPED: a Yes Z-No (NOTE : MAXIMUM FREE-FALL DEPTH IS 301) <br /> o SOIL BORING Q HAND AUGER APPROX. BORING DEPTH 30 F2G 7— WOLTED TRAFFIC BOX or U STOVE PIPE <br /> a OTHER: 11 OTHER 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: "I certify that in the performance of the work <br /> for which this permit is issued, 1 shall not employ persons subject to WORKERS' COMPENSATION Laws of California." Contractor's hiring or sub- <br /> contracting signature certifies the following: ") 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 /> THE-APPILPeAN M s G CAt 1?1$y NOl2 QN ',SIR D/H�A 1G F WALL 17EQ'Ft DQtNSP£ ��IS <br /> Signed x / TitleG414/1� Date ! � <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED : <br /> DEPARTMENT USE ONLY <br /> Application Accepted By �� z L�4 , Date Issued Area O 7 S_tc <br /> Grout Inspection By - Dale Final Inspection By Date <br /> Destruction Inspection By le --e G Date <br /> COMMENTS/ �I C-O`NDITIONS: -�._�/ <br /> it G.�LC4 ef4 V.or/Dz . c:, �/e Lv-F '2-e. ,. ,-f c;- cc P fS <br /> LPECOD3ESFEE <br /> NTING ONLY: AID#O AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT I SERVICE REQUEST # INVOICE <br /> — lq iuoa `/ / <br /> G57 LICENSED GONZ!RACTOR WIST SIGN I.ICpjWE k"RKEPS' COMPEPiSATIO)IV DECO ARALIDN <br /> UNIT IV - 6/23/99 /sign bkpg/MI <br />