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• ORIGINAL' <br /> WELL PERMIT APPLICATION FORM UNIT IV S� <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E.Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 4683449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct andfor install the work described. This application Is made in compliance with <br /> San Joaquin County Development Tnie,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental sHealth Division. <br /> WELL Loraion 2-3.�tlo``S'l 5'. sa4at FC. /cans Cross Street City r • Tn� 7`dp'11,f3�7 Pa .9Y2-070'/D <br /> PROPERTY Ownety/.OS¢, ✓,� Address 23c, <br /> S9 S. fu n�A Ff. ity / '^LZip`/'3�7 Phonep�` Yby"Z <br /> '_a _ <br /> C•67 Contractor iJrj144az�n1- Jlddress'+Z33 F Mzuevvd 6 Cityt%+!+d,,,G..•ir•+2Zip 457 L Lidi SS VII Phone y/G 63d-727G <br /> Consultant l Sub Contractor 1;e WZ -VL-.4e1 AddresS00ktlor ?Ikrx'Ulow City"-4, Lic# t'102- Phone#yl $LI-04ay- <br /> GIS Coonlinates:X .Y .Township 3 5-0- Range_L&±_& Section Z'1 <br /> WORK TO BE PERFORMED <br /> OEW WELL I BORING(CPT.GlZEDBE,HYDROPUNCIa.HAND-AUGER,OTHER-) p DESTRUCTION(choose type below) <br /> !SOIL BORING# 0 OVERBORE <br /> .WELL# MW-7 aPRESSURE GROUT <br /> 'Other. <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECQIIFICATIONS <br /> MONITORING JQiOLLOW STEM —� DIA.OF BOREHOLES MULTIPLE CASING57 p YES ,�NO WELLCASING DIA: -I� <br /> 0 EXTRACTION 0 AIR HAM)AERR7RNEN CASING THICKNESSStk4- y0 TYPE OF CASING: 0 STEEL XPVC Ij OTHER: <br /> G VAPOR 0 MUD ROTARY DEPTH OF GROUT SEu /(o I TREMIE TYPE TO BE USED: ZAUGERS WHOSE <br /> OAIR SPARGE ;PUSH POINT GROUT SEAL PUMPED:_Yes p No (NOTE:MAXIMUM FREE-FALL DEPTH IS 301) <br /> SOIL BORING 'a 0 NANO AUGER APPROX.BORING DEPTH tl0 tBOLTED TRAFFIC BOX or 0 STOVEPIPE <br /> 0 OTHER: (I OTHER CONDUCTOR CASING PROPOSED?—,610_(If YES,list specifications here): <br /> COMMENTS• • _ _ _ .�—C'� <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 agents signature certifies the following:-1 certify that in the performance of the work <br /> for which this permit Is issued,I shall not employ persons subject to WORKERS'COMPENSATION taws of Califomla." Contractor's hiring or sub- <br /> contracting signature certifies the following:"I certify mer in the porformance of the work for which this permit is issued.I shall empldypersons subject to <br /> WORKERS'COMPENSATION Laws of Califomia" <br /> :G4L113-14U.NkT11l1k P CTORWiWPk ([�1,73R�iINADV3114IOE1FOEtISLIyf2EG3UIREDIIQSPIEG Ip S <br /> Signed x y/�- TidelCompany 5r4%L -J .Ac.ry VTOAw 7.hC. Pr• .>r M`t <br /> Print Name�JG'tc FiU L�ILr�Gvic Data <br /> ,r I _ <br /> DEPARTMENT USE ONLY �I ��OU N, Brea `• <br /> Application Accepted 8y Date Issued (� <br /> Grout Inspection By "' Date 8 /e Final Inspection By <br /> Destruction Inspection By Date / <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES PEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT(SERVICE REO UEST# INVOICE <br /> Il WJ 0/23 1v 19M 0023 <br /> 1/18/2000 <br />