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7-01-1999 3: 13PM FROM P. 3 <br /> i <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 f <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:s 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 /> Assessors <br /> WELL Location INI W• Sf!A 2d . Cross Street W 114 City Zip q3 Parcel# <br /> ,� _ BuR� . — Newpv��C Ncw t <br /> PROPERTY Ownerp �{QcY-G/I_,;L-IP Address e Z3(F City__(AeQrk Zip�(2 (,D Phone# 326 ZS _UW8 <br /> C-57 ContraUorf(0`aftUll C"1Q,t)$¢�J-(QSAddress(�3$ yitGu4STt'ia! }U( c;tC,,.. Jd SI22_ 22+8 4431 2Z� <br /> ((//�� 3 Yom` ZipQ Li '_Phone 0-G <br /> Consultant/Sub ContractorCQ�'wL S�ttitS Address BW City f:�11✓1141d- Lic# Phone#90 353 03'-7D <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH, HAND-AUGER,OTHER') ( type below) <br /> �DESTRUCTION(choose <br /> SOIL BORING# 17 OVER-BORE <br /> `Other: WELL# 13 PRESSURE GROUT <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Q MONITORING ,-10LLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?Q YES 0 NO WELL CASING DIA:t/4 <br /> 0 EXTRACTION 17 AIR HAMMER/DRIVEN CASING THICKNESS _TYPE OF CASING: 17 STEEL 0 PVC a OTHER: <br /> p VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: AUGERS OHOSE <br /> Q AIR SPARGE p PUSH POINT GROUT SEAL PUMPED: Q Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH 2D �+. Q BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> Q OTHER:_a OTHER CONDUCTOR CASING PROPOSED? Y110 _(if YES,list specifications here): <br /> ZOMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> 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 /> ±ontracting signature certifies the following: "l certify that in the performance of the work for which this permit is issued, I shall employ persons subject to <br /> NORKERS'COMPENSATION Laws of Califomia." <br /> THE APPLLCANT WUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed x Title_ Date 01 //O/`�68Q <br /> SEE SITE MAPUNIT IV WORK PLAN DATED <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Issued Z D <br /> 3rout Inspection By Date Final Inspection ByDate <br /> )esiruction Inspection By V _JDate <br /> :OMMENTS/CONDITIONS: ..Cil -t c-� 00%p <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED BY DATE PERMIT/SERVICE REDDEST NUMBER INVOICE <br /> yn <br /> 7�2. 2q-6 Is Gw ? DZ j fig" <br /> :: - .` <br /> 047-MIC SED-CON.; .. ,''�;`�. ,t �'`6I1?TC1IrNSk&�4 )�R'$' <br /> JNIT IV-6/23/99/sign bkpg/MZ " <br />