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9-22-1999 Q-00PM FROM Y <br /> IRFC`FTVED <br /> WELL PERMIT APPLICATION FORM <br /> M <br /> e <br /> B <br /> AN .lOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL. HEALTH DIVISION ("PHS-EHD") <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 Q <br /> (209) 4G8-3450 W <br /> NPIRES 1 YEAR FROM DATE ISSUED <br /> Application,s hereby made to San Joaquin County for a perrru't to constnsct andfor install the work described. This application is Mde in compliance vnth <br /> San joaqu,n County Development Title,Chapter 4-11151 and the Standards of San Joaquin County PuNIC Health Services,Enviroonnm ��Health 0%vision <br /> sesDA-V St. Cross street��Ib{,�t 5T City Sracki�l �p Q- S�oS =Parcel# <br /> WELL Location a E <br /> E AI"da c ockten z-p fS D Phon o9- <br /> g37_8.��' <br /> PROPERTY Owner Gi��! B F STD f�1l>� Address 5 N �► <br /> C-57 Contractor ?� <br /> �$s p 1 city Up.�=L,#ff ,ones x,15=313:s8" <br /> Consultant!Sub Contractor '1'VL 1"TQ <br /> 6611- Address D p�fv'rl t• City wicw►R L,at ' �`��7°7'935-yas� <br /> GIS Coordinates X Y <br /> Township Range Secuon <br /> WORK TO BE PERFORMED <br /> p DESTRUCTION(choose type below) <br /> NEW WELL f BORING CPT EOPROBE HYDROPUNCH HAND-AUGER,OTHER") p OVER-BORE <br /> SOIL BORING#_:5 PRESSURE GROUT <br /> p <br /> WELL� <br /> 'Other <br /> COMMENTS <br /> E OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS �lNO WELL CASING DIA <br /> NITORING U HOLLOW STEM DIA.OF SOREHOLE 121 -MULTIPLE CASINGS 13YES Pe <br /> EXTRACTION a AIR HAMMERIDRIVEN CASIN 4 TYp OF CASING a STEEL p PVC 0 OTHER <br /> �VAPOR p MUD ROTARY DEPTH OF GROUT SEAL_ <br /> TREMiE TYPE TO BE USED n AUGERS dHOSE <br /> AER SPARGE PUSH PAINT GROUT SEAL g Yes No (NOTE; MAXIMUM FREE-FAIL DEP } <br /> )(SOIL BORING <br /> HAND AUGER APPROX.BORING DEPTH ffS (]BOLTED TRAFFIC BOX or STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? N (if YI=S list speaficatzons here) <br /> 3 OTHER <br /> r <br /> COMMENTS <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS! <br /> 1 hereby certify that!have preoared this application and that the work veil be done�n accordance with San Joaquin County Ordinances State Laws,and Rules <br /> and Regulations of the San Joaquin County Homeowner or t,cernsed agent's signature certifies the following "1 caftify that,n the performance of the work <br /> for which this permit u issued:I shall not employ persons subject to WORKMAN S COMPENSATION Laws of California." Contractor's hrrrng or nut <br /> contracting signature certsros the fatic—mg -1 certify that in the petfermance of the work Far which this permit)s tssued I shelf omploy parsons sublet!to <br /> YYORKMAN'S COMPENSATION Lays of C9111h rn2 ` <br /> EAP NT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS <br /> Signed x <br /> SEE SITE MAP I UNIT IV WORK PLAN DATED 3 <br /> DEPARTMENT USE ONLY ^ "o 1 <br /> Qate tsaued a <br /> Appl,eamn Accepted By Fsnal Inspection By <br /> Grout <br /> e- <br /> Grout inspection By Dare <br /> Destructlon Inspection By Al <br /> Date <br /> OMMENTS 1 CONDITIONS* <br /> F <br /> ACCOUNTING ONLY- Alfa <br /> PE CODES FEE INFO AMOUNT REMITCED CHECKIIfCASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE <br />