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11-OS-1999 11 :41AM FROM • • P. 3 <br /> �DPY <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work dascribed. This application is made in compliance with <br /> San Joaquin County Development Title.Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> ZO Z�PJ, ��FG TD STVC i�TnN/ Arcel# is/y S_D 3 U6 <br /> WELL Location Cross Street City / Zipp,..�-,��ParceW? <br /> PROPERTY OwnermUN 'Z- F'4""tLNTI Addre55y0f :ocE,1.,i �I CkycONS LAGI� Zip��'S"b PhoneiNjD �'OIZ} <br /> 1276 NEy Y�IZ <br /> c-5?contradorS�£CT ✓w` r AddreasZ36S In/IGi�/Am A' cityS�' zip ucfn5' Phone#�r( <br /> Consultant/Sub ContraCWCHZV"k 1+(u- Addrea44'LnAu L-pR, CityWOC7 `6 Lic# Phone#5'3JZ//3. W <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED , t ... . rr <br /> JEW WELL I BORING(CPT.GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) a DESTRUCTION(choose type below) <br /> a$OIL BORING# nT/_ ./Itr . G�/r DOVER-BORE <br /> a WELL# _ .TG a PRESSURE GROUT <br /> •Other. <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFIC IONS lr <br /> MONITORING HOLLOW STEM DIA,OF BOREHOLE S / MULTIPLE CASINGS?a YES '7d0 WELL CASING DIA:Z <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESSTYPE OF CASING: a STEEL 6PV� a OTHER: <br /> G VAPOR a MUD ROTARY DEPTH OF GROUT SEAL Q-'Ib TREMIE TYPE TO BE USED. a AUGERS aHOSE <br /> a AIR SPARGE a PUSH POINT GROUT SEAL PUMPED: a Yes a No (NOTE. MAXIMUM FREE-FALL DEPTH IS 10') <br /> G$OIL BORING a HAND AUGER APPROX.BORING DEPTHz2 - 1; XEBOLTED TRAFFIC BOX or G STOVE PIPE <br /> G OTHER; a OTHER CONDUCTOR CASING PROPOSED? (if YES, <br /> YES,list specifications here); <br /> COMMENTS: 7 ' z0 T /1�C^1,r t['t„vL 4J LLL-S <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby Certify 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 /> and Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: "1 certify that in the perforrrranco of the work <br /> for which this permit is Issued,I shall not em loypersons subject to WORKERS'COMPENSATION Laws of California.” Contractor's hiring or sub- <br /> contracting signature certifies the following: " rt/ty,that in the performance of the work for which this permit 1s issued,I shall employ pefsons subject to <br /> WORKERS'COMPENSATION Laws of /110mis" <br /> AP LICANT ST,_CALL 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED IINfSPEC,,TIONS. <br /> Signed x Title <br /> S.G£o LO G,SI Date Jr2Lr OJ <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED' r� zoos r <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Issued ✓ reit(-�� <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: �• <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 290 toovw S C.. 3 2 rOC�ZZZ�( Z— <br /> Cr57 LICENSED'CONTRACTOR.M7JST SIGN LICENSE&WORKERS' COMPENSATION DECLAKATION <br /> UNIT TV-6/23/99/sign bkpg/MI <br />