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- <br /> I <br /> WELL PER 1. APPLICATION FORM UNIT IV <br /> I <br /> I <br /> I <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL. HEALTH DIVISION (PHS-EMD) <br /> 304 E.Weber, Third Floor, Stockton, CA., 95202 � <br /> (209) X468-3A49 <br /> NON-REFUNDABLE PERfiMIT EXPIRES 1 YEAR FROM DATE ISSUE£? j <br /> plication Is hereby made to San Joaquin County for a permit to construct andlor install die work described. This application is made in compliance with 1 <br /> Sen Joatluin Courcy Development Tae,Chapter 9-1775,3 and the Standards of San Joaquin County Public Health Services,EnvimAss�ors ealth Division. <br /> 4 rg,i i in e�CrossEtreat e !r.' &,/City Traczipy7�74 parcel# ! <br /> WELL Location 3 S 5 G - <br /> ir y >an <br /> lone tag}835- t39za <br /> PROPERTY Owner � J'r°r�'c Addrzss �+ City ZiP <br /> C•57 Contractor 85!fi S 6reAddress 9So Howe 20 0 of City rnQ ^4ZIp YsT3 Lie#�85/L5 ( <br /> phone# TLs)3 7- seo� <br /> I u� 5 C9l61 s64 ss�S <br /> consultantiSubContravtor Address �SzG�irrrure ��� Gityr_ � —Lig# Phan <br /> GIS Coordinates: <br /> Y Township Range Section <br /> fk. � <br /> I: WORK TO BE PERFORMED I <br /> NF-W WELL 1 BORING(r—FT,GEOPRO9E,HYDROPUNGM,HAND-AUGER,OTHER") Q bESTRUGTION(choose type below) <br />` 0 SOIL.BORING# OVER-13ORE <br /> &WELL# /I V1 77 L✓z PRESSURE GROUT <br /> •Other. <br /> COMMENTS: <br /> TYPE_OF WELLINSTALLATION TYPE CONSTRUCTION SPECIFICATIONS Ili <br /> MONITORING �IOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS? YES EEL WELL CASING DIA:Z <br /> EXTRACTION p AIR HAMMER/DRIVEN CASING THICKNESS -SC4, 4 d TYPE OF CASING: �STEEL PVC Q OTHER:_ <br /> d VAPOR Q MUD ROTARY DEPTH DP GROUT SEAL O- 3r TREMIE TYPE TO BE USED: AUGERS dHOSE <br /> 0 AIR SPARGE d PUSH POINT GROUT SEAL PUMPED: n Yes WNo (NOTE-MAXIMUM FREE-FALL DEPTH IS 30') <br /> n SOIL BORING n HAND AUGER APPROX.BORING DEPTH 15 l �1BOLTEA TRAFFIC BOX or p S1 OVE PIPE <br /> s here : <br /> CONDUCTOR CASING <br /> PROPOSED? U [if YES,list specification } <br /> [)OTHER; <br /> COMMENTS: OTHER CONDO . <br /> i <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> :I hereby certify that I have prepared this application and that the wore will be done in aocordance with San Joaquin County Ordinances,Stipa Laws.and Rules <br /> d Regulations of the San Joaquin Counter. Homeowner or licensed agent's signature certifies the following: "I certify thof in�e performance of she Work <br /> which this permit Is issued i shall not employ persons subject to WORKERS'COMPENSATION Laws of Cafifiomia." Contractorsum <br /> 's hiringZ or <br /> contracting signature certifies the following:1 Gortify that in the performance of the work far which this parmit is issued,I&heli employ persons subject to <br /> E WORKERS'COMPENSA TION laws of Califamia.° r <br /> NS`A�E <br /> R--AEON.- !! 1lsitfR;x;�N ADS(o.k`N.r—g k)~ F C IR1=t 5. 5 S <br /> signed x <br /> Title company �r <br /> Print Name <br /> �Lr, r.' Ca r Dateims <br /> I <br /> DEPARTMENT USE ONLY Lze c( 31 <br /> Application Accepted 6y ° z ` C' Date Issued I- /'T-C�40 Area D.7 5tI <br /> Grout inspection By Date Final Inspection By Date <br /> 47 <br /> r`t)estruction Inspe ction By Date <br /> COMMENTS I CONDITIONS <br /> S L m>s ff <br /> tt r w 4fi vv^ <br /> ACCOUNTING ONLY: AID# <br /> E <br /> PE CODES FEE INFO AMOUNT REMtTTED CHECK# REC'D BY DATE PERMIT!SBRY1cE REgtlEST INVOICE <br /> SC?1 fr/w 33 <br /> L.1,41, <br /> 3 3 O A-A A <br />` l\ c u P S T'tj <br />