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>N:;' _ Za—'9S9 10: 1 1 Ari i-ROH P. a <br /> i <br /> WELL PERMIT APPLICATION FORM UNITIV <br /> r ' <br /> 4 AN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-E FID) <br /> 304 E. Weber, Third Floor, Stockton, CQ., 95202 <br /> (209) 458-3449 APR 12 20 0 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUEE) i <br /> Apptcati5n is hereby made!o San Joaquin County for a permit to construct andtar install the work described, This application is made in cempli�lnce with <br /> San Joaquin County Development Title,Chapter 9-11,.5.3 and the Ltsnd2rdS Of San Joaquin County Pubiic Healt" $ervtres, EnvironmcntAl Health]ZlMsiot, - <br /> 1��� r f wr .i , -_ -1 Assessors <br /> WELL Location.l c�W- S Cross Street City SAM ktox Zip 915 710I Parcel* <br /> I PROPERTY Owner �f�tA _J � (ria... AdCress Q30S Ow'\Aa p IA. C`ii'y Sk1� Zip 45Z�t Phar�#t q�� " 5%414 3 <br /> C-9-7Contractor VNN 'b Cf k t Address �' 7�t Jul Cityip,44571L1c4+?O104 PhCne# <br /> A <br /> Consultant l Sua Contractor .If�Ct- I�a;JL.14s Address W4 4R City riwtlL:ha Lis# Phone#5 '7-Z 7 1 <br /> GIs Coordinates:X Y Township4 Range Section <br /> WORK TO BE PERFORMED <br /> )IEW LVEI_L I BORING(CPT, EOPROBE,HYDROPILINGH.HAND-AUGER,OTHER-) p DESTRUCTION(choose,type tr® 1bw <br /> �r\\ CIL BORING# E (j OVER4e0RE <br /> Q WELL# �PRESSURE GROUT <br /> 'other: <br /> COMMENTS: <br /> YIPE OF WELL INSTALLATION TYPE CONSTRUCTIO PECIFICATIONS <br /> 0 MONITORING �IOLLOW STEtu1 DIA. Of BCREHdtE �� MULTEPt E CASING57�]YES O ,WELL'CASING 01A: <br /> a EXTRAG T ICN p AIR HANIMEr71ORIVEN CASING T}!iCKNESS TYPE OF CASi,tG: a STEEL p PVC I.0 OTHrZR. <br /> a VAPOP, p MUD ROTARY DEPTH OFGRCU7 SEAL So' TRl WEv TYPE TO SE USED: )(ALlGEPS OHGSE <br /> p AIR SPARC ;E Q PUSH POINT GROUT SEAL PUMPED: X'es p No (NOTE: MAXIMUM FREE-FALL DEPTH iS 30') <br /> `,r_OIL BORING II HAND AUGER APPROX. BORING DEPTH SOLTE"O'rRAFFIC BOX or c STOVE PIoC <br /> U OTHER; 1]OTHER CONDUCTOR CASING PROPOSED? NA (if Yr;s,list specifications here): <br /> COMMENTS <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> s hereby;xR;fy;hat I have prepared this application and that the worX wiii be done in accordance with San Joaquin County Grdtnances,State Lavrs,and Ru1as <br /> ane Regulation.$of the San Joaquin County. Homeowner or licensed agent's signature certifies the'ollowrna: "l certify that In the performance or the work <br /> W which this permit iS ivwed, I shall not employ Porsons Su41j9Ct to WORKERS'COMPENSAWON,taws of California." Contractor's lining cr sub. <br /> COnttaCting signature owlifies the fo;'cwrr-g 'l cer°,ry thd' 'the po+7011n10ce of the worts for Nhid,this Perth,,,s:ssusd, I`half employ parsons stipjecr to <br /> I'YORKERS'COMPENSATION Lavrs <br /> _ of Califon rra" <br /> THE APP_DANT STCALL-48 WORKING HRS IN ADVAN E FORALL-R.E-QUilRED.JNSPECTIONS_ <br /> Signed ��_J� 0.- <br /> 7itie P Ll WLx�J Ca � <br /> to - -- - <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED'.., <br /> DEPARTMENT USE ONLY <br /> a ppiiaatian Accepted By v y Date iasusd Area <br /> Grout Inspection By Date Final Insrssction� Daie <br /> Desi^,action inspection By Date <br /> CONituiENl'�I GONDI�ION � �r - ly�p�i` <br /> VV <br /> ACCOUNTING ONLY'. AIDY <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# Rt.C'o BY' DATB PERMIT 1 SERVICE itE4UEs7 v I INVOfGE <br /> 3 50q.n35 Z <br /> C-57 LICENSED;CONTRACTOR MUST SO'RI�ERS'C0_MPE1_SaATJOI`i..DECI..A,kATION <br /> UNIT LV-6123/99/:;;9n bk99/M1 <br /> { <br />