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9 09-1999 19 :39AM FROM-. <br /> WELL PERMIT APPLICATION F <br /> rECEaffb <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD)SEP 141999 <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209)468-3449 ENVIRONMENTAL HEALTH <br /> PERMIT/ SERVICES <br /> NON-REFUNII]ABLE PERIIAIT la(PIRES 1 YEAR i= <br /> Application is hereby made to San Joaquin CROM DATE ISSUED <br /> ounty for a permit to construct andlor install the worts deseribed, This a li <br /> San Joaquin County Development Titter Chapter 9-11115.3 gnd the Standard`s of San,.Joaquin County PrJbiiC HeStth Seri/ices.lEnviiQn is ronmental Health Division,i <br /> WELL Location ��CaF�LLI:,(5 <br /> &=LC-- <br /> 2# Cross Street 6"-1 CC 2.c d-SG, rj� Gj Q Assessor'st� City l v.3— 0S 0-05 <br /> PROPERTY Owner 7t.� AcECress. 4OC ,� C• OYt yS �t-� <br /> ,t - —� -- Y Zip �jO�Phon 2i �!9SL•� <br /> C�57 Contractor VW �r r�l, �} 17 61 Address.#'-�-lr7W� City�[2i� Zi 9Lic#�zo9 <br /> I PIC.E - Phon 7d7 7c/,2,375 r <br /> Consultant/Sub Contractor L�POI Cc ,cs Address .2 7`f/4ime <br /> City m t iG#,�1�i7 Phon SKe <br /> otina­­'GIS Co <br /> — Townshipj Range , <br /> _Section 3 r3 I <br /> WORK TO BE PERFORMED <br /> E1 NEW WELL I BORING(CPT,GEOPRODE,HYDROPUNCH,HAND-AUGER,OTHER <br /> D SOIL BORING# DESTRUCTION(choose type glow) <br /> "Other. Q WELL# t'I't L,) Ve--w E�OVER-BORE <br /> A P—L 4EPRESSURE GROUT <br /> COMMENTS: Sick �Jo2l� P/c �7cc�e r �'g ri,�?I c� nvri �t A <br /> TYPE O�WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE <br /> Q EXTRACTION. 0 AIR HAMMER/ORNEN CASING THICKNESS_ MULTIPLE CASINGS7iQ YES �]NO WE4i.CASING DIA; <br /> TYPE OF CASING: a STEEL []PVC 0 OTHER: <br /> hj�IAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL <br /> Q AIR SPARGE Q PUSH POINT" .-._._TREfVIIE TYPE T4 BE USED: j]AUGERS �]H('}SE <br /> GROUT'SEAL PUMPED; 0 Yes n No (NOTE: MAXIMUM FREE-FALL DEPTH 1S 30') <br /> (1 SOIL BORING 0 HAND AUGER APPROX.BORING DEPTH <br /> Q BOLTED TRAPFIC BOX er p STOVE PIPE <br /> Q OTHER; 0 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 1 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 perM4 is issues',I shall not employ persons subject to WORKERS'COMPJ=NSA71ON Laws 4f California." Contractor's hiring or sub- <br /> contracting signature Certifies the following: -1 certify that in the performance of the work for which this permit is issued, I.shall empioy.persons su6jeet to _ 1 <br /> OMPENSATION Lays of Calrfornia" M <br /> TI"I L,.,., N. .M•..... .CA , ,4"*60,KIN(§ HRS IN ADVANCE FOR ALL R1wQt11RE[9 II:ISPI=CTIQAIS. <br /> Signed x � 1 <br /> Title Z'1�'�-Rle6 ...._._Date L? (8 9 <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED: j <br /> DEPARTMENT USE.ONLY { �j <br /> Application Accepted ay__ ! ' l. OtZA Date issued 1 y ---Area I <br /> Grout inspection By Dat® Final Inspection B Date <br /> Destruction Inspection 8y I, Date <br /> C0141MENTS NODI IONS ;G <br /> O <br /> l <br /> ck 7-1 <br /> ACCOUNTING ONLY: AID# L <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATEPIwRMtT I SERVICE REQUEST# INVOICI: <br /> 57 LICEN EDC ..CEASE <br /> uiarT ry-6izsi�s lsi n b�' I" GN?. ON Z pq ARATTQN <br /> � �AC'I'��c:MUS'T�S� CO�i'ENS1�T� <br /> ps <br />