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:7af Z l/ZVU2 11 Ub 2094683433 FIFTH FLOOR PAGE 03 <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) 468-3450 <br /> NON-REFUNDA13LE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Applicalion is hereby made to San Joaquin County fora permit to construct andfor install the work described This application is made in compliance with <br /> San Joaquin County Development Title,Chapter 9-1115 3 and the Slandards at San Joaquin County Public Health Services Environmental Health Division <br /> C ITY S I d 6 w h l tCI N F A v H T I?I= Assessors <br /> WELL Location <br /> 13 0 N H VH TE R 5 k E:P T Grass Street E.W ES I:R AV Eeily STOCiNTO N zip5-NIT 02 ParcelA <br /> I <br /> PROPERTY0wneiEAC LSAN IAST t�oE l Address I41'11,5COITS RYE: <br /> GIy j0Gk10f4 zip9 5105 Phonef168'335} <br /> iZAHt 4 <br /> C 5]Contractor.MI7c 9 E ll 0 RIILJ N G Address it b q Zip §_fi 0 Lic*1416ITPhone#(31 h)631-3T,8 3 <br /> Consultant I Sub Contractor RA M 14 6 E F-110,V, Address P,0.130% 669 CityMy R IE T Licl1 5 8 5 6 PhoneAt (9(6) 3 S 4-31 S 0 <br /> GIS Coordinates X 'Y Township Range Section <br /> WORK TO BE PERFORMED <br /> I NEW WELL I BORING(CPT GEOPROBE HYDROPUNCH RANO-AUGER OTHER ) a DESTRUCTION (choose type below) <br /> 11 SOIL BORING# a OVER-BORE <br /> 'Other WELL N Vit- W- []PRESSURE GROUT <br /> COMMENTS TWO QFF-SI,TE CrIZOUrDWATER MONETOKIMGW6LE_ <br /> TYPE DF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING III HOLLOW STEM DIA OF BOREHOLE 9-iN MULTIPLE CASINGS?11 YES I NO WELL CASING DIA' '�N <br /> 0 EXTRACTION o AIR HAMMER/DRIVEN CASING THICKNESS SC N 40 TYPE OF CASING flSTEEL JPVC U OTHER <br /> IWAPOR D MUD ROTARY DEPTH OF GROUT SEAL 16- F T TREMIE TYPE TO BE USED §AUGERS []NOSE <br /> IR SPARGE 0 PUSH POINT GROUT SEAL PUMPER a Yes 1 No (NOTE MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING []HAND AUGER APPROX BORING DEPTH 35" F T I BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> 0 OTHER CONDUCTOR CASING PROPOSED? No of YES, list specifications here) <br /> COMMENTS <br /> NOTE, OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS! <br /> 1 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 /> ana Regulations of the San Joaquin County Homeowner or licensed agent s signatute cert,lles the following "I certify that rn the performance of the work <br /> for which this permll is Issued,1 shall not employ persons subject to WORKMArCS COMPENSATJON taws of Callfornla" Contractors hiring or sub- <br /> contracting signature ceni8es the following 'I coady that in the performance of the work for which thrs perrrid is issued I shall employ persons sub^f to <br /> WORKMAN S COMPENSATION Laws of Cahlomra ' <br /> H@rAPPL1CAfV 48 HRS IN ADVANCE FOR ALIL/RE UERED INSPECTIO ct <br /> M Signed x'f'� <br /> Tice "' [ Date Z f Z <br /> SEE SITE MAP IN UNIT IV WORKPLAN DATED --f I6 , o l <br /> DEPARTMENT USE ONLY <br /> Application Accepted By� Date Issued Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Oestrucban tnsped*n By Dale <br /> COMMENTS I CONDITIONS <br /> FAC* <br /> ACCOUNTING ONLY AtD# <br /> CODES I FEE INFO AMOUNT REMITTED CHECKIWCASH RECEIVED BY I DATE PERMITISERVICE REQUEST NUMBER INVOICE <br /> SR# O o 30 3 v <br /> UNIT IV-6/1/99/sign bkpg/MI <br /> i <br />