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FILE CO <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES `, <br /> Ate lfw <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3450 <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 CoWtF <br /> elopment Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division <br /> Mi NcA/CTN u)Z Assessor's <br /> WELL LocationAS+ (< !XI, -S 7-, Cross Street 1?off A City_7-/,A C: Zipcl3.374 Parcel# <br /> Y C)�-f/C'✓�N..r'0,U S . S,f N <br /> PROPERTY Owner VNl DN ?A CIFt L ISA)iRoAO COAddress s r=h. 00R City iTgA, i Cc Zip%y)OS Phone'- `f 1S S'S/ 7vw <br /> C-57 Contractor/A L u 71,;::K941 o, DiL&Citi/. Address A 0 . Sox 7 11 7 City Pc cAsANr ZipPhone#cl i L-`)`))-Z`i'1.9 <br /> GAfa✓c <br /> Consultant/Sub Contractor40LuS ILChNfu0(�)cS Address29*9 IAl)�Cli)�J DRQ.4�City P,o✓,7-AIN Lic# 3�yHi Phone#bs�''�/b0-)lvti0 <br /> ✓)mow <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> I NEW WELL/BORING(CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER-) 0 DESTRUCTION(choose type below) <br /> 0 SOIL BORiNG# 0 OVER-BORE <br /> WELL# (� =LLS 0 PRESSURE GROUT <br /> 'Other: �PGX !�g '. , :52 <br /> COMMENTS: <br /> TYPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br /> I MONITORING i HOLLOW STEM DIA. OF BOREHOLEff MULTIPLE CASINGS?0 YES I NO WELL CASING DIA:Z 4 Y <br /> EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS5CH. vo TYPE OF CASING: 0 STEEL I PVC 0 OTHER: <br /> 1 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 3' d y TREMIE TYPE TO BE USED: 0 AUGERS (HOSE <br /> 0 AIR SPARGE /PUSH POINT GROUT SEAL PUMPED: 0 Yes !No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH lo' To l(a BOLTED TRAFFIC BOX het i STOVE PIPE <br /> 0 OTHER: CONDUCTOR CASING PROPOSED? NO (if YES, list specifications here): <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 WORKMAN'S 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, I shall employ persons subject to <br /> WORKMAN'S COMPENSATION Laws of California." <br /> THE APPLICANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed x �- r 11 Title r-I t L,) J'VeLF-11vi f4g:- Data J V 4-. r tri i`)c) <br /> —T <br /> SEE SITE MAP IN UNIT IV WORK PLAN. DATED <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Issued � 6 Area—e�b—fl <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: lO <br /> FAC# <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED BY D TE PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> 29� <br /> C-57 CONTRACTOR SIGNATURE QUIRED ON BACK V I <br /> UNIT IV-6/18/99/sign bkpg/MI <br />