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" � • UNIT IV <br /> WELL PERMIT APPLICATION FORM <br /> SAENVIRONMENTAL HEALTNTY BH DIVISION PHS-EHD)LIC HEALTH S <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct andlor install the work described. This application is made in compliance ivision. <br /> Assessor's {�kr <br /> San Joaquin Count Development Title,Chapter 9-1115.3 and the Stand�dsMtof (J in County Public Health Se 46 Z02v�Parcel#al Health Division. <br /> 5,iwvlkC�1mfac A• . • or <br /> Zip — =7— <br /> WELLLocation5de lk 6o-oE Mr..er Cross Street A.�w $� City SFocl.� P <br /> °I25 N• EI'Dor"o5A.city 5���`I-"' Zip 452°7-Phone# 4-93�-84e1 <br /> PROPERTY Owner L o� � Ck4� Address 7oT-$74-y$� <br /> V p9`lS71 Lic#710e7 Phone# <br /> ISO $cX 336 CitY&0 ts6 Zi <br /> c-57 contractor In .^ Drt�lww Address 7214 Phone#416-631- 1300 <br /> 31�10 Qold G..e Or � � ���� ' <br /> D.rl 4 cTza , MO City orl�i <br /> Consultant I Sub Contractor -' �'1" O - 9 Imo• Address__- <br /> - Range Section <br /> Township�— <br /> GIS Coordinates:X_�Y��—, <br /> WORK TO BE PERFORMED 0 DESTRUCTION(choose type below) <br /> *NEW WELL 1 BORING(CPT,GEOPROBE, HYDROPU CH;HAND-NUGER,OTHER-) 0 OVER-BORE <br /> 0 SOIL BORING It 0 PRESSURE GROUT <br /> WELL# MW�26 -S C '6(ArS,G <br /> *Other: n <br /> COMMENTS: n 3 <br /> TYPE OF WELL INSTALL_ A_TION TYPE CONSTRUCTION SPECIFICATIONS <br /> Q YES I$.NO WELL CASING DIA: <br /> 'MONITORING g'HOLLOW STEM DIA.OF BOREHOLE S" MULTIPLE CASINGS? �Y <br /> 0 EXTRACTION 0 <br /> AIR HAMMER/DRIVEN CASING THICKNESS S D TYPE OF CASING: a STEEL WVC a OTHER: <br /> p VAPOR p MUD ROTARY DEPTH OF GROUT SEAL3S 6TREMIE TYPE TOM USED: 0 AUGERS OSE <br /> �'AFR SPARGE OZaN& N PUSH POINT GROUT SEAL PUMPED: Pres 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> H •Ia 6� <br /> 0 SOIL BORING 0 HAND AUGER APPROX.BORING DEPTBOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER: 0 OTHER CONDUCTOR CASING PROPOSED? No (if YES,list specifications here): <br /> 1 lo3 x ozor¢ e c I rL <br /> COMMENTSvv�nv\ to r•� r r t 1 R< r 60 d' ``'r <br /> u s o �f c '/0 65 R I t o / <br /> OTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT FERMI S <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: "1 certify that in the pesubjechlowork <br /> contractingormance <br /> signature certifies the followin '1 certify that in the performance of the work for which this permit is issued, I shall employ persons for which this permit is issued,1 shall not employ persons ubject to WORKERS'COMPENSATION Laws of California." Contractor's hiring or sub- <br /> for <br /> 9 g <br /> WORKERS'COMPENSATION Laws of California." <br /> T AP [CANT MUST CALL 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTION <br /> � /(�HE[) (//,JL, Title 5e rt l7v^)co t5� Date <br /> Signed x VC /�✓'" .. <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED: 102 -7/01 <br /> DEPARTMENT USE ONLY Area <br /> Date Issued <br /> Application Accepted ByDate <br /> DateInspection By <br /> Grout Inspection By <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AID# - <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# <br /> REC'D BY DATE PERMIT SERVICE REQUEST# INVOICE <br /> C-57 LICENSED CONTRACTOR MUST SIGN LICENSE&WORKERS' OMPENSATION DECLARATION <br /> UNIT IV-6/23/99 /sign bkpg/MI <br />