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WELL PERMIT APPLICATION FORM NIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES d� <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) � <br /> 304 E. Weber, 'Third Floor, Stockton, CA., 95202 R8,� <br /> (209p 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/Qr install the work described. This application is made in compliance with <br /> San Joaquin Co jvel ment Title, Ch�,p r 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br /> �� �I '� cafrar /401/0&✓ Ad, Assessor's. <br /> WELL Loc tion S/6�E. o� Coir.t fl.11o� R Cross Street Wes l' 11 n^ S�% City� Zip 9S-3?-G Parcel# 232-170-0-5- <br /> 102' S. ar 'S.P. Rail /sad fiq�ky <br /> PROPERTY Owner_ A;1 Sur/1.5 Address PO t'3oA 17-6 City 1-,f .cti Zip 9s39(2Phone#&0J)835-`1130 <br /> C-57 Contractor Prcc iS ion .Swmet;nTAddress_I`lDO S. SOTg 5+. City RiG4Lic#(3L3 �Phone#�S ) d�M _q <br /> Consultant/-&� r Address 2101 lWe h5 fo. 5 i City 04 k t ono) Lic# Phone#AS/oS 663-yJt;4 <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> ` Dt�1AE1AfEt l / ORING CPT, GEOPROSE,HYDROPUNCH, HAND-AUGER,OTHER PvtM. 0 DESTRUCTION(choose type below) <br /> 'SOIL BORING# G lAA - Z$ 'M° locr;"� v;N1 be bocwftt\ed []OVER-BORE <br /> []WELL# wi}y ceM.nl yr.�; wif~+ a }ytriit p�pc, <br /> 'Other: PRESSURE GROUT <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING []HOLLOW STEM DIA.OF BOREHOLE 3`' MULTIPLE CASINGS?0 YES )(NO WELL CASING DIA: Na <br /> []EXTRACTION []AIR HAMMER/DRIVEN CASING THICKNESS AIA TYPE OF CASING: []STEEL a PVC []OTHER: <br /> 0 VAPOR []MUD ROTARY DEPTH OF GROUT SEAL A/A TREMIE TYPE TO BE USED: []AUGERS []HOSE <br /> a AIR SPARGE PUSH POINT GROUT SEAL PUMPED: []Yes jrNo (NOTE: MAXIMUM FREE-FALL DEPTH IS,30') <br /> SOIL BORING []HAND AUGER APPROX. BORING DEPTH IS-.'2 o' []BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER:_G OTHER CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> COMMENTS: ;/oG1 P✓V,% ria LJ;LI At-IA io cx)QovE 15--'20' i 1AShIlt �erKpo�vr.. IDla Pyc- t,✓Ut Sc-eec anal <br /> t SiA .s4in It /o✓ndr.Jo✓�in CAAIC 01111 6C +10-!JCAW G4M<+aoa/� t,Jin l: <br /> NOTE: OFFSITE BORINGS REQUIRff 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 /> 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: 'I certify that in the performance of the work for which this permit is issued, t shall employ persons subject to <br /> WORKERS'COMPENSATION Laws of California." <br /> T PPLICANT MUST CALL 48 HRS IN ADVANCE FOR ALLREQUIRED INSPECTIONS. <br /> dZI <br /> Signed x Title 0`�" 7�G7 �G. Date <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED <br /> DEPARTMENT USE ONLY LC} <br /> Application Accepted By Date Issued !Z// O Area <br /> Grout Inspection By Date Final Inspection By <br /> ate <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> FAC# <br /> ACCOUNTING ONLY: AID# I <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#!CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> 210 oo �� <br /> C ?LI~1SD CQNT .ETOR ST_ � 1 ,LTCEISE&WK1C� rE, ( EG. Q <br /> UNIT IV-6/23/99 /sign bkpg/MI <br />