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. WELL PERMIT APPLICATION F RIlltl UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHP) <br /> 304 E. Weber, Third Floor, Stockton, CA.,-95202 ` : r 'i I <br /> (209) 468-3449 ORIGINAL <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 /> Assessor's <br /> WELL Location 290 N. M'3in Sf�et Cross Street 1t'th Stet City Zip9`�� Parcel# -01 <br /> PROPERTY OWnealard & Dalcres Cc1r� Abdress FO BDK 1022 City Mmlbem Zip95336 Phone#209-239-4141 <br /> C-57 Contractor WW DC l l iM AddressFO BDx 51 City UlSta Zip9!KT Lic#720904 Phone#707-374M5 <br /> Consultant/Sub Contractor Address City Lic# Phone# <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> I NEW WELL/BORING(CPT, GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER") 1]DESTRUCTION(choose type below) <br /> SOIL BORING# Q OVER-BORE <br /> WELL# '3 PRESSURE GROUT <br /> "Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> i MONITORING II HOLLOW STEM DIA.OF BOREHOLE lli� rr MULTIPLE CASINGS?0 YES II NO WELL CASING DIA: <br /> 0 EXTRACTION D AIR HAMMER/DRIVEN CASING THICKNESS 4I© TYPE OF CASING: 0 STEEL 11 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL Z-t r TREMIE TYPE TO BE USED: a AUGERS 1HOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> 0 SOIL BORING p HAND AUGER APPROX.BORING DEPTH &t' E-+ 4 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER: 0 OTHER CONDUCTOR CASING PROPOSED? KZ (if YES,list specifications here): <br /> COMMENTS: C�--p AttPx+yyJ M= <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 Son Joaquin County Ordinances,Slate 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,t shall not employ persons subject to WORKERS'COMPENSATION Laws of California" Contractor's hiring or sub- <br /> contracting signature ce,tifies the following: V certify that M the penbrmanoe of the wwrk for which Ibis permit is issued;1 shell employ pe sons subject to <br /> WORKERS'COMPENSATION Le s of California." <br /> T E"APPL ICW MUST aLL;41�'WC'HI `1f+];`' 'k! !k1' " I 'i4 GtiJl� <br /> ;...,... .. r. <br /> Signed x Tale a111�� Date `� r <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED:ONLY <br /> Application Accepted By DEPARTMENT USE Date Issued l�—F-19 ( O�t1 T <br /> —Area— <br /> Grout <br /> reaGrout Inspection By Date Final Inspection By ww <br /> Destruction Inspection By Data <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AID* <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUESTS INVOICE <br /> 3501 -'rim I <br /> ��,57 ZIGP,i1vSFaT?,'CC3 i�Ivt�]!S* L a::i <br /> , ..:�: •. .. .,: ,:. .. •.. T'sT'I:�;�:'. .,.,,_._.__......_.,����.�G''EE� ',.,�... . .,..,. :_....�§ ,��S�l�AE.�L:ARA.'i'IO� <br /> UN.rT IV- 6/23/99/sign bkpg/MI <br />