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WELL PERMIT APPLIGAT,6VI ^& UNIT IV <br /> �'vi R'CjI�i"!I!-:"iTAi, HEALTH <br /> SAN JOAQUIN COUNTY PUBLIC HeALY14 56WI ORIGINAL <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 /kAS Ayn 1110 u4 <br /> E (209) 468-3449 t W A� j r-- >~t+,+y <br /> f ; <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Applicatlon is hereby made to San Joaquin County for a permit to construct andlor install the work described. This application is made in compliance with <br /> San Joaquin County Developmen Title,Chapter g-1115.3 and the Standard�of San Joaquin County Public Health Services,Environmental Health Division. . <br /> Assessor's f <br /> WELL Location- Z `_ V5T t V Cross Street ~ Cily-� OL�T7� Zip Qr?^Parcel#/' <br /> PROPERTYOwner pp e 'A Address 1 r - u CitY�q tR?Zip�S�b PhanelF(7�5y Z�iG�ly3 C� ! <br /> C-57contractor-iv -PNJ - AddressT� �DX WSJ 1 Cit-{1 (0 ��Zip�._f' Licit � PhortJ69 r7 �i7 ^gj I ! <br /> Consultant I Sub Contractor T r `VA L. Address Z ro C. T r City7�Lic# f- Phos Zd� ?/ 8 13T <br /> GIS Coordinates:X Y ,Township Range Section <br /> F <br /> WORMS TO BE PERFORMED <br /> a } <br /> WELL!BORING(CP ii <br /> YDROPUNCH,HAND-AUGER,OTHER') Q I <br /> 111 Q DESTRUCTION(choose type below} <br /> OVER-BORE <br /> WELL# RiNC3 Ir 0 PRESSURE GROUT <br /> `Other. y <br /> COMMENTS: ec f Ar-u I A 1 <br /> I <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS „ir14- <br /> O MONITORING a HOLLOW STEM DIA.OF BOREHOLE Z7-2 '� MULTIPLE CASINGS?BYES ONO WELL CASING 01A: <br /> EXTRACTION O AIR HAMM£RIDRIVEN CASING THICKNESS Ps TYPE OF CASING: O STEEL II PVC U OTHER: <br /> O VAPOR []�UD ROTARY DEPTH OF GROUT SEAL I• .o C TREMIE TYPE TO BE USED: D AUGERS OHOSE <br /> O AIR SPARGE 'PUSH POINT GROUT SEAL PUMPED: O Yes (NOTE: MAXIMUM FREE-FALL DEPTH IS 311 <br /> YV H (]BOLTED TRAFFIC BOX or U STOVE PIPE <br /> ©SOIL BARING O BAND AUGER APPROX.BORING DEPTH <br /> O OTHER. OTHER CONDUCTOR CASING PROPOSED? ('rf YES, list specifications here): <br /> COMMENTS: <br /> J: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby certify that I have prepared this application and that the work witl 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 cartifies the following: "!cer[ify than in fire performance of the work <br /> for which this permit is issued,f shalt not employ persons subfect fo WORKERS'COMPENSATION Laws of Cafitumia-" Contractor' sub's ring 0 1 tosub- <br /> contracting signalure cerilties the following:7 certify that in the performance of the work for which this permit is issued,I shelf employ pe s J <br /> WDRKPRS'COMP SATION Laws of Cafifomis." r lfV"ADIiI� " g' <br /> Oi4 A�1CMOR..!�g���_R* � ll�r �Pl�ti,���RED"iN <br /> TitlelCompany C' `-A C I`U L�C+1 erb( 6tS/ <br /> Signed x <br /> f 2r� Date Z <br /> Print Name <br /> �zSa� <br /> DEPARTMENT USE ONLY <br /> Date Issued Area Q <br /> Application Accepted By <br /> Grout inspection By Date Final 1nSpectian By <br /> Z <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> f ' <br /> ACCOUNTING ONLY: AIF# i <br /> PE CODES FEE INFO AMOUNT REMITTED CHEII RECD BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> Qi <br /> 3501 7•��/: -Z� Z vits/cow <br /> 79 �7bd <br /> N00-1A HI-�IA EE1aE89Za50Z ZE=pI 000 /9Z/p9 <br />