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7-01-1999 3: 13PM FROM- P. 3 <br /> U U <br /> r <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - 6LLt <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 Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> Cross Street�L 4 l —City p�s <br /> Assessor's <br /> WELL Location � Zi Parcel# <br /> ✓1 -L40 1J WQo(+- � q%j or <br /> PROPERTY Owner A�drdres'sL�Dc-W .,p S fP 23 1 T City Zip4 U40 Phone#C/L-L.$; -( k I <br /> C-57 Contractor�� l �l I Address-,?50 r7Dli1P Fd( CityNa/hfte Zip 1f-313 ic# 5 (!S Phone#� -SSOD <br /> Consuttant/Sub Contractor EQ(4k !j:!�j S feiS Address4-41�53 LWar'n S'�riCityr:amat Lic# Phone#5/fL-35� <br /> 13 J <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> OEW WELL/BORING(CPT,GEOPROSE, HYDROPUNCH, HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> ,Q'SOIL BORING# CPT-[ +RrtA (-PT--J g OVER-BORE <br /> 0 WELL# 0 PRESSURE GROUT <br /> 'Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE_MULTIPLE CASINGS?p YES 0 NO WELL CASING DIA: jib <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS NP' TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS CHOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH 4.D f-f 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> ;KbTHER: UT- p OTHER CONDUCTOR CASING PROPOSED? A (it YES,list specifications here): <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> 1 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 /> WORKER 'COMPENSATION Laws of California." <br /> THE APPLICANT ST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed x Title w ate f /U J 5� <br /> SEE SIT MAP IN UNIT IV WORK P N DATED <br /> DEPARTMENT USE ONLY �7 <br /> Application Accepted By Date Issued - 8'O <br /> Grout Inspection By Date Final Inspection By <br /> Destruction Inspection By Date <br /> COMMENTS i CONDITIONS: �p 7` woo oU <br /> ACCOUNTING ONLY: AID# FAC# <br /> =CODESFEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> qo( f 712.0c, Z 8(015 21 qgy; <br /> C=S L•I ENSED CCs'�t'i`) 'AC >EJ T I 7 E.1�TS Si S3 i -f ' F i t t71V <br /> UNIT IV-6/23/99/sign bkpg/MI <br />