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WELLPERMIT APPLICATION FM 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 Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br /> I Assessor's . <br /> WELL Location 180 161-1 P&CtPt, AvCnve- Cross Street V-kLlnor 54- City, 54roe-146y, _--.Zip 45202- Parcel# 644 ROW <br /> PROPERTY Owner Cr �9,--4-6,n Aodress '125 M. G1 %)%me6 5}. City Zip $2o2Phone#20q-437-83•IQ <br /> C-57 ContractorVja4 a,,erj Grillino Address TO 1t5o�r 336 Cityg,o Visk.._Zip 91571 Lic#2IooT Phone#707-37*1-gJ40 I <br /> CftC&41e.r-Ry oIre , , I . ' r S <br /> Consultant/Sub Contractor Dau _b W. r m Address pg4D OOIJ 6,A gr 17o Cityaonaiv +aa,Lic# �2 t L Phone#`i+b•691 13ao <br /> GIS Coordinates:X Y ,Township Range Section <br /> WORK TO BE PERFORMED <br /> 'KNEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER") 0 DESTRUCTION(choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE <br /> WELL# w-20 t+ -2 (]PRESSURE GROUT <br /> "Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> O <br /> MONITORING STEM OIA.OF BOREHOLE $�� MULTIPLE CASINGS? YES �'NO WELL CASING DEA: Z <br /> 0 EXTRACTION [I AIR HAMMERIDRIVEN CASING THICKNESS Sc1� 40 TYPE OF CASING: STEEL PVC 0 OTHER: <br /> VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL `�s t?$ TFiEMIE TYPE TO BE USED: [J AUGERS iOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: Wes D No {NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER APPROX, BORING DEPTH 60' 4 40' MOLTED TRAFFIC BOX or [I STOVE PIPE <br /> 0 OTHER: 0 OTHER ` CONDUCTOR CASING PROPOSED? NO (if YES,list specifications here): <br /> I <br /> COMMENTS: <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. "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 Califpmia." 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, 1 shall ernploy persons subject to <br /> WORKERS'COMPENSATION Laws of.Califomia." <br /> .".u..m .. ,.. F ...._., <br /> Ti .. AP ,LI ANT MUST�CALL 481lYORKING HRS.IH ADVANCE,FORrALL REQUIRED INSPECTIONS; <br /> Title, -1 lii!rn to r eo tog 5 Date �'�i 3 OZ i <br /> Signed x <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED: Oeeem)b <br /> DEPARTMENT USE ONLY <br /> Date Issued -r a Area <br /> Application Accepted By ti Date 3 160y. <br /> l Date d 2Final lnspection'By- <br /> Inspection ection B Y <br /> p <br /> Date <br /> p <br /> Destruction Inspection By r , <br /> COMMENTS!CONDITIONS,_ <br /> lQac.� c. LO' Mal. P G S- +� <br /> MA.CCOUNTiNGAID#AMOUNT REMITTED CHECK# R£C'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> C=57;LICENSED:CQNTRA CTOR MUST.SIGN LICENSE.&compENSA'TiON;DEGI.ARA <br /> TION <br /> UNIT IV-6/23/99 /sign bkpg%MI <br />