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11-05-1999 11 :41AM FR0 . P R I G N A L <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 described. 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 /> All, <br /> '/ �^ Assessor's/y s_ 7 <br /> WELL LccationZOZ� A • CCHn�tLTO'\l Cross/s,,Street Cky77VC�ro` Zip Parcel# <br /> PROPERTY OwC�ne++rMOJJ(£rL FA` i,�TR 'S Addres5'/OIEG OC&'4 44 301 City/4-al amµ rpQL Phone#3/D�fl�'c�129- <br /> 657 Contraotor P9C IT`S W\� I Addres ,zX WIL W,9+� 'Py—. City5fa4 'JZ,p Lic#S/Zu'�hone#�(`/ES BTt 2-. <br /> Consultant/Sub ContractorGwyk k+(LL- Addrea34�+?JAMV-art• CayI �P+IJG ud+ Phone#5301g5ST9'E <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED i ... _) +r <br /> )(NEW WELL I BORING(CPT,GEOPROBE, HYDROPUNCH, HAND-AUGER,OTHER-) (]DESTRUCTION(choose type below) <br /> Q SOIL BORING# to 5 fi Q OVER-BORE <br /> Q WELL# _ .�G Q PRESSURE GROUT <br /> 'Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFIC IONS rr <br /> MONITORING {HOLLOW STEM DIA,OF BOREHOLE / MULTIPLE CASINGS?Q YES 'YNO WELL CASING DIA:Z <br /> 0 EXTRACTION Q AIR HAMMEWDRIVEN CASING THICKNESS -7TYPE OF CASING: Q STEEL Q PV Q OTHER: <br /> Q L <br /> VAPOR Q MUD ROTARY DEPTH OF GROUT SEA "ICJ TREMIE TYPE TO BE USED: Q AUGERS QHOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: Q Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 12 SOIL BORING Q HAND AUGER APPROX.BORING DEPTH ZO -lV1 BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> 11 OTHER: Q 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 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: "I certify that in the performance of the work <br /> for which this permit is issued,I shall not employ persons subject to WORKERS'COMPENSATION laws of California." Contractor's hiring or sub- <br /> contracting signature certifies the following: " anlfy that in the performance of the Werk for which this permit/s issued,I shall employ Persons subject to <br /> WORKERS'COMPENSATION Laws of Nlomra <br /> AP, LICANT ST CALL 48 WORK ING,HRS IN ADVANCE FOR ALL REQUIRED INfSJPECTIONS. <br /> Signed x Title <br /> SEE SITE MAPINUNIT IV WORK PLAN DATED' +�Fi�5 <br /> O <br /> (/t DEPARTMENT USE ONLY �(} <br /> Application Accepted By Date Issued jS TTT <br /> Grout Inspection ByDate Final Inspection By <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: 7171W <br /> ACCOUNTING ONLY: AID# FA <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> Zgo I ` OW(.1S � - 3 2SR# 'OaZZZ Z— <br /> C,57 LICENSED'CONTRACTOP,,MUS'I',SIGN LICENSE—W,--KEIiS''COMPENSA'ION DECLAkATION <br /> VMIT IV-6/23/99/sign bkpg/MI <br />