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F <br /> WELL- ERMIT­ACPPi1CATI0N F'tAM UNIT IV <br /> VU,? <br /> 4 P SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES FILE <br /> �� <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 /> + :- Assessor's <br /> WELL Location — Cross Street 6 c54✓e ±city 57oG e_44, Zip Parcel# - <br /> aZ,oZR� �us-f F✓e�uoyr{'c51 <br /> T1 /� :/ ,�•/ a to <br /> r PROPERTY Owner Vt11ON 1.01M OA1AtN5Address �• 0QO�C IpZ,b City bG4Nb S Zip�� t'�hone# '500 <br /> iO <br /> C-57 Contractor \I+Wy*-WNq Address � . �CX JAI City tOVt�tgZipft4§T�ico72b504phone# 1� <br />+ - 5011 67 Do✓4do CEG/ G'1 I ) <br /> Consultant/Sub Contractor LnrJ '�w7J. Address Pa✓I�_fit Su• 7City 14i 11S Lic#+k143zPhone# -1 BI ,(Ca l70 <br /> GIS Coordinates:X , Y Township' Range Section <br /> j _ <br /> WORK TO BE PERFORMED ' <br /> 41 NEW WELL/BORING(CPT,GEOPROBE, HYDROPUNCH, HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> Q SOIL BORING# Q OVER-BORE <br /> 3 t IVELL# M W-1 M �3 - Q PRESSURE GROUT <br /> 'Other: � , <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS - <br /> MONITORING V(HOLLOW STEM DIA. OF BOREHOLE MULTIPLE CASINGS?Q YES Q NO WELL CASING DIACZ <br /> p <br /> Q EXTRACTION Q AIR HAMMER/ORIVEN CASING THICKNESS ScIA 4-a TYPE OF CASING: Q STEEL OVC a OTHER: <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUTSEAL TREMIE TYPE TO BE USED: Q AUGERS OSE <br /> Q AIR SPARGE Q PUSH POINT GROUT SEAL PUMPED: aces Q No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> Q SOIL BORING Q HAND AUGER APPROX. BORING DEPTH SS� p�iOLTED TRAFFIC BOX or Q STOVE PIPE <br /> Q OTHER Q OTHER CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> COMMENTS: <br /> 'r NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby certify that I have prepared this application and that the workwill be done in accordance with San Joaquin County Ordinances,State Laws, and Rules <br /> and Regulations of the San Joaquin County. Homeowner orllicensed',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." Contractors hiring or sub- <br /> contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, /shall employ persons subject to <br /> WORKERS'COMPENSATION Laws of Califomia." _ _ ' <br /> THE APPLICANT MUST CALL 48'W I RKING,HRS IN ADVANCE.FOR-ALL REQ(UIRED�INSPECTIONS, <br /> Signed z .. .• Title KPe ttifV2� L')Co(Oa+�rDate d . <br /> P <br /> SEE „SITE dP IN UNIT .IV WORK` PLAN DATED: h_71 `i 9 <br /> w m DEPARTMENT USE ONLY // q <br /> Application Accepted By - Date Issued 0�[ 9 Area <br /> r <br /> Grout Inspection BDate Final Inspection By ,.:Date <br /> Destruction Inspection By y .Date -. <br /> ! COMMENTS I CONDITIONS: *t /-P 5 W• <br /> ACCOUNTING ONLY: AID# FArft <br /> - - <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> C=57,LICENSED CONTRACTORMLJST SIGN=TSCENSE_&WORKERS'GONIl'ENSIITION:DECLARt1TIOlYf <br /> UNIT IV-6/23/99/sign bkpg/AAI �*" <br />