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, 1 <br /> • • <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) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a.permit to construct and/or install the work described. This application is made in compliance with <br /> San Joaquin County evelopmen T'tle ha er 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> Q,, 3 t��l r„IV a /� �1 I 11 Assessor's <br /> WELRoiation 0.S NG( Cross tr t Ilkorn\0. City �?oG`<'t"o`'t Zip9S2o2 Parcel# 139-2`x-09-7 <br /> AJ1 + rIa9 a ernes + cI' sso e# <br /> PROPERTY Owner Address 5. % 2S0 Cit p one# <br /> C-57 Contractor lAJoa�..+� /n'YY'l�tlw. �j Address f�o'6ox 33'6 1 CityR�oVl r— rip qS��I Lic# L1U -�I Phone# 1oi-374'�13da <br /> (�t144gr- Kwn I„C Address NW old Dn ?40 City{�A.tw Ctrt .Lic#220793 Phone#916-631-Gat) <br /> Consultant/Sub Contractor � <br /> GIS Coordinates:X <br /> Y—,Township Range Section <br /> WORK TO BE PERFORMED <br /> NEW WELL/BORING(CPT, GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> SOIL BORING# 0 OVER-BORE <br /> WELL# L -tttU-I,2� ()— I D PRESSURE GROUT <br /> *Other: <br /> COMMENTS: <br /> TWEOF ELINSTALLATION TYPE CONSTRUCTION SPECIFICATIONS r. <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE g n MULTIPLE CASINGS?0 YES g;NO WELL CASING DIA: _ <br /> 0 EXTRACTION AIR HAMMER/DRIVEN CASING THICKNESS S � TYPE OF CASING: STEEL $,PVC OTHER: <br /> VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL SLG 1461 , TREMIE TYPE TO BE USED: AUGERS OHOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: ; Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH Sec Ix Io`�J �CBOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> p OTHER: a OTHER CONDUCTOR CASING PROPOSED? (if YES,list specifications here): f' <br /> COMMENTS: uJGII U'II �I) = 30.�r,- Gra�F$m.( -kn 16F'4'• - wcll U I2 T>) = 120{{: ra.v�$eo-I�'o 10(0 ery.,� <br /> Uic l l U 13 T D -70�¢ Ct few Sta l o �6 Fk <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: ' certify that in the performance of the work <br /> for which this permit is issued,I shall not employ persons subject to WORKERS'COMPENSATION Laws of California.” Contractor's hiring or sub- <br /> contracting signature certifies the following: '7 certify that in the performance of the work for which this permit is issued, I shall employ persons subject to <br /> WORKERS'COMPENSATION Laws of California." <br /> y(yy( A p`�L6 NT MUST CALL (48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed x <br /> ,✓ �` l lRV 1 O' 1-7G(_Zo4 Title s Date Z l 2'L l � <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED: Nabec 12, 14RR <br /> ,Q DEPARTMENT USE ONLY <br /> Application Accepted By `�I/>7 ' "� a Date Issued 3'o7-O �� Q Area q K� <br /> '- rD-CU <br /> Grout Inspection By <br /> Date Final Inspection By�'b1 Date s' <br /> Destruction Inspection By Date <br /> r� 1 / <br /> COMMENTS I CONDITIONS: U I I In O Qr J -{fit -.12351 <br /> LIEF IUgg L -1 <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 15500 o ft <br /> C-57 LICENSED CONTRACTOR MUST SIGN LICENSE&WORKERS' COMPENSATION DECLARATION <br /> UNIT IV-6/23/99/sign bkpg/MI <br />