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8 26—i 999 a:�`d!✓M r Kurt • e- <br /> WELL PERMIT APPLICATION FORA UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICE�F-" <br /> ENVIRONMENTAL HEALTH I]IVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 '~' <br /> (209)'458-3449 <br /> r <br /> KOflt-REFUNDABLE PERMIT EXAIRIr'S I YEAR FROM DATE ISSUED u1; i�1--,r�,r <br /> Application is hereby made to San Joaquin County for a permit to construct andlof Install the worK describes, This appGcatOagi d'e Ih, <br /> San Joaquin County Development Title.Chapter 9-1115.3 and the Standards off San Joaquin County Public Health Services, Environmental t c;Zon. <br /> WELL Location ? �� ((� Cross Street F t qty OR <br /> �S / <br /> p r arcalx –3�0– p <br /> PROPERTY Ownar' -'> Address ��0� ,a :p `f5$3Phone#Rx" <br /> CS7 Contractor v Address 15 tC ciQ2D <br /> dY Z S LI Phone# Ib-77]-q/pp <br /> Consultant/Sub Contractor&L4 'a {41kjAddress�G mSt 3fie <br /> �-- ��C+tY � ✓ Lire Phone#�'�"`(?-(?–,331.E <br /> GIS Coordinates:X <br /> �—:Y TownShiD _Range Section <br /> MRK TO SE PERFORMED <br /> [ANEW WELL/BORING(CP'r,GEOPROBE.HYDROPUNCH,HAND.AUGER,OTHER') <br /> 0 SOIL BORING a �LPESTRUCTI (choose type below) <br /> 'Other. j1WELL# o W 17 5 `� mw 5 �,�) VER-t30RE <br /> Q PRESSURE GROUT <br /> COMMENTS: t( 4411 f l I <br /> TYPE OF WELL INST TION TYpE C NSTRUCTiON SPE FIX;AT10N5 <br /> �MON170R1NG �Ia-tpLLOVy STEM +, r 1 <br /> DIA.OF BOREHOLE _MUL71PLE CASINGS?0 YES )j NO WELL CASING DIA: � <br /> 0 EXTRACTION I]AIR HAMMERIDRIVEN CASING THICKNESS L 17 TYPE OF CASING: 0 STEEL 1%FVC —TT <br /> 0 VAPOR 0 MUD ROTARY DEPTT-I OF GROUTSF�4L 9u Q OBER: <br /> 0 AIR SPARGE PUSH POINT T•REMIE TYPE TO BE USED: a AUGERS )WiOSE <br /> 0 GROUT SEAL PUMPED: 0 Yes Po (NOTE: M"MUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER APPROX. BORINGDEPTH / / <br /> 0 OTHER*___________o OTHER OLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSE 7 _ (if YES,list <br /> specifications here?: <br /> COMMENTS: Y1 se- e N ltd <br /> NOTE: OFFSI E BORINGS REQ IRE AC SS OR ENCROACHMENT PERMITS <br /> I hereby cartity that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,State Laws.and Rules <br /> arta Regulations of the San Joaquin County, Homeowner or licensed agenrs signature certifies the following: '7 certify <br /> that in the as,State <br /> La s. the work <br /> for which this pernature er issued,1 shy/1 not employ persons sirbJect to WORKERS'GOMPFII►SATION Laws afCallthat in Contractors hiring or sub- <br /> WORK Ing signature certifies following: 7 certify Char/n the performance of me work for which this permit is issued,I shall employ persons subject fa <br /> WORKERS' MPF/VSATIQ Laws of California," <br /> 4TE AP LICANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPE T NS. <br /> Signet!x <br /> Date <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED <br /> DEPARTMENT USE ONLY <br /> Application Accepted$Y G-�.f//_ � (/�� <br /> 3rout Inspection By ,Date Issued <br /> Date <br /> Destruction Inspection By Final Inspection By <br /> Date Date <br /> -OMMENTS/CONDITIONS: - <br /> 6_/_1✓17 <br /> h^` �4•S c am}li /I'1 L IM' J <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED He6eWCASH RECEIVED BY DATE PERviIT/SERVICE REQUEST NUMt3ER INVOICE <br /> C-57 LICENSED C©NTRACT MUST SIGN LICENSE &wOF�RS, CONT T�Ot�T r�'£CI..s�,�'��� <br /> NIT IV- 6/23/99/sign bkpg/,VtI <br />