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d <br /> FOR <br /> UNIT IV <br /> WELL PERMIT APPLICATION FO <br /> SAN JOAQUIWCOU,NTY PUBLIC HEALTH SERVICES <br /> r� <br /> ENVIRONMENTAL'li'HEALTH DIVISION ("PHS-EHD") <br /> 304 E. Weber,,Third Floor, Stockton, CA., 95202 <br /> (209) 468-3450 <br /> I <br /> NON-REFUNDABLE PERMIT EXPIRES1 YEAR FROM DATE ISSUED <br /> C., rll <br /> Application is hereby made to San Joaquin County for a peimit,tb construct and/or install the work described. This application is madeJn compliance with <br /> San Joaquin County Development Title,Chapter 9.1115.3 and.'the Standards of Sari'?Joaquin County Public Health Services,Environmental Health Division. <br /> C F-K F.r(xY Assessor s <br /> WELLLocation hARWNtr WAY CrassStreet I-Alit= City S OCKTOI`I Zip >�-201_ Parcel# <br /> SAN J0AGLV11R . ! (209) rl <br /> PROPERTYOwner CATI}GLI•C CEMET R�Addrefss ,Q.Q:I3 II CityS'lWL TOR zip 9510l Phone# kid-6242_ <br /> MtTerM�LL "ill r ! (�lit4ciAo ( 916 ) <br /> C-57 Contractor l�4 G RN/, Address 1061$ Htt°g220 WA`( `i CiIyCORDOVA-Zip9�36�0 Lic#���6I�Phone# $52-15�� <br /> r. IRANc-HO R,G-, g16) <br /> Consultant I Sub Contractor R A M&G-1= E`101. ;Address O ' A City M V S I I<TA Lic# 5 S 5 L., Pirrone# 3 5`t- 3 1 5 <br /> I GIS Coordinates:X Y 7 .c Township � Range Section H <br /> WORK TO BE PERFORMED <br /> NEW WELL I BORING(CPT,GEOPROBE, HYDROPUNC} ;.HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> o SOIL BORING# t" []OVER BORE <br /> j <br /> WELL# Mw- M W- Fug 0 PRESSURE GRQUT i <br /> 'Other: s r i I <br /> COMMENTS: i <br /> TYPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS ! <br /> MONITORING 1 HOLLOW STEM DIA.OF BOREHOLE 8~IN.Cti MULTIPLE CASINGS?a YES I NO WELL CASING DIA: Z-IN <br /> EXTRACTION AIR HAMMER/DRIVEN CASING THICKNESS SCRI r'1 O TYPE OF CASING: d STEEL J PVC 0 OTHER: <br /> DEPTH O <br /> F GROUT SEAL ?6 5 I TREMIE TYPE TO BE USED: 1 AUGERS 0HOSE <br /> MUD ROTARY <br /> �VAPOR � ' <br /> p AIR SPARGE PUSH POINT GR6UT SEAL PUMPED: p Yes I No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> Sar 1 <br /> ©SOIL BORING HAND AUGER RPpROk BORING DEPTH 0 r _ I BOLTED TRAFFIC BOX or a STOVE PIPE <br /> OTHER: CONDUCTOR CASING PROPOSED? NQ (if YES,list specifications here): �A <br /> COMMENTS: <br /> $ Tfl ;Glrr A: WtLt GL'Vi lF- ; . MW- 0A To GE 50 ` D�Ep, i <br /> MV11A AND MW - 8 <br /> Mw- 5� TO T�� TS ' DEtR.1;:. t <br /> NOTE: OFFSITE BORINGS`'".R,5QUIRE ACCESS OR ENCROACHMENT PERMITS! <br /> I hereby certify that I have prepared this application and that.lhe woik will be done in accordance with San Joaquin County Ordinances,State Laws,and Rules <br /> and Regulations of the San Joaquin County. Homeowner orlicensed agent's signature certifies the following: "I certify that in the performance of the work ! <br /> for which this permit is issued,I shaft not employ persons subject to WORKMAN'S COMPENSATION Laws of California." Contractors hiring or,sub <br /> contracting signature certifies the following: "I certify that iii the performance of the work for which this permit is issued, I shall employ.persons subject to. <br /> WORKMAN'S COMPENSATION Laws of Caiifornie." ? r: <br /> HEA LICANT U 7 ALL RS IN ADVANCE FOR ALL REQUIRED INSPECTIO S. � <br /> cll I S Date -Z « Qz <br /> Signed x Title <br /> ;i <br /> F i i <br /> c o <br /> 'i <br /> SEE SITE MAP IN UNIT L WORK PLAN. DATED 12 I 1 <br /> t7EPARTMENT USE ONLY <br /> /� Z t <br /> Application Accepted By t t Date Issued C� 6 Are �.I <br /> " n6 � <br /> � d� Final Inspection By Date <br /> Date <br /> Grout Inspection ./-�/>1 �L <br /> n <br /> DateI <br /> :h.. . : <br /> Destruction Inspection BY <br /> COMMENTS I CONDITIONS: <br /> FAC# <br /> ACCOUNTING ONLY: AID# ' f <br /> PECODES FEE INFO AMOUNT REMITTED CF3 GASB RECENED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE <br /> 07 <br /> UNIT IV-6/1/99/sign bkpg/MI <br />