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WELL PERMIT APPLICATION FORMIr <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES JAN 1 4 2002 <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202,y 'e _ g <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED application is made in compliance with <br /> Application is hereby made to San Joaquin County for a permit to constructs of S install the work described. This app Assessor's <br /> San Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Parcel# 1 gq-ItZ,losio17 <br /> /°q C r1 r A.,�, Cross Street Ca 1,�o�nw City $I'oGk;-en Zip 4S <br /> WELL Location 8788 BlkGoav SIV4. <br /> v°. Zi 9S62y Phone#4k+-71`I-325 <br /> 1t sn Addressn -- •1. 1$ city Elk Gro P <br /> PROPERTY Owner 11'^^"I COrOOIW l-� - 9/$71 uc#7/00-19 phone#xv-3v�/- q3010V�� II Address <br /> 11 ID On 0. Y 33k CityR,o \154- zip <br /> C-57 ContractoriUo-�ab�b I <br /> 'He rie(% Address2lf Id Cp�17bCitY�° <br /> C yic{ '7211 Ph9 -637- 1300Consultant/Sub Contractor <br /> Range Section <br /> GIS Coordinates:X�l Y�l Township <br /> WORK TO BE PERFORMED 0 DESTRUCTION (choose type below) <br /> ( NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 OVER-BORE <br /> 0 SOIL BORING# a PRESSURE GROUT <br /> �94NELL# 5V- Gsip-3G <br /> •Other: <br /> COMMENTS: 31 n <br /> TYPE OF WELL INSTALL_ AVON TYPE CONSTRUCTION SPECIFICATIONS <br /> Q MONITORING INSTAYHOLLOW STEM DIA.OF BOREHOLE a �� MULTIPLE CASINGS?0 YES 0jd0 WELL CASING DIA:_. <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS SGI� WO TYPE OREM EI TYPESTEEL TOBE USEDPV O GERSOTHER NOSE <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 40 <br /> O VA SPARGE OZONE 0 PUSH POINT GROUT SEAL PUMPED: 'Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING D HAND AUGER <br /> APPROX.BORING DEPTH 7-I_�XBOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER: 0 OTHER <br /> CONDUCTOR CASING PROPOSED? 1`/4 (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 /> sub- <br /> for <br /> which this <br /> err t is cer <br /> tifies the fol shall <br /> ln not le artlo ily that sonsin the subject once of he work for t to WORKERS' which sthis permit s ATION issued,of lI shall employ tpe persons sub subject to b <br /> 9 9 9 perform <br /> WORKERS'COMPENSATION Laws of Califomia.' <br /> Tye AP LICANT MUST CALL 48 WORKING HRS IN ADVANCE//FOR ALL REQUIRED INSPECTIONS. <br /> ('� �. Title r l9t °+ s Date ! // <br /> Signed x J`/ �� / <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED: <br /> DEPARTMENT USE ONLY Area <br /> Date Issued <br /> Application Accepted ByDate <br /> Date Final Inspection By <br /> Grout Inspection By <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> DATE PER ERVIv� EOUEST# INVOICE <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY 'R <br /> C-57 LICENSED CONTRACTOR MUST SIGN LICENSE&WORKERS' OMPENSATION D <br /> TION <br /> UNIT IV- 6/23/99/sign bkpg/MI <br />