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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 <br /> • (209) 468-3449 FILE COPY <br /> i NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 4pplication 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.� �,[ ' " / p Assessor' <br /> WELL Location 15101 -5• 7� - �` r- .:ross Street G _ _ . City l Ad Zip f 5330 Parcel# fG -IS <br /> 41 - 7PROPERTY Owner Address . / 75 $ 2j <br /> ' � � Mddress s3�© S. hJp' - AVS, City qlb <br /> C-57 ContractorM7el/NhQIfl[Ur(iIlW- v /c0 X29 ; <br /> - { <br /> APP d � ,L ) I/' 209) <br /> Consultant/Sub Contractor �f+DawhV ptJMCi'i*J;]r X-Address 'ICOS-/J.I`,1)fW J , City 7DCk&OLic# Phone#_¢G,�-/U(7to <br /> GIS Coordinates:X <br /> 'y ,Township Range Section -II <br /> r <br /> WORK TO BE PERFORMED - <br /> I <br /> ¢,NSW WELL I BORING(CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER,OTHER-) p DESTRUCTION(choose type below) <br /> p SOIL BORING a OVER-BORE <br /> d,. Q*ELL# t !.7 PRESSURE GROUT <br /> 'Other: �t/(�(jf/ Y b <br /> COMMENTS: i <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS [ <br /> ONITORING OLLOW STEM DIA. OF BOREHOLE Srr MULTIPLE CASINGS?O YES 0<0 WELL CASING DIA:7- If <br /> O EXTRACTION O AIR HAMMER/DRIVEN CASING THICKNESS54. +0 TYPE OF CASING: O STEEL (,[}PLIC O OTHER: <br /> ]VAPOR O MUD ROTARY DEPTH OF GROUT SEAL 10 G y TREMIE TYPE TO BE USED: - 1GERS OHOSE <br /> O AIR SPARGE p PUSH POINT GROUT SEAL PUMPED: O Yes (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') i <br /> O SOIL BORING O HAND AUGER APPROX. BORING DEPTH 2870 $Of A� <br /> Y--945<LTED TRAFFIC BOX or O STOVE PIPE <br /> O OTHER:_0 OTHER CONDUCTOR CASING PROPOSED? A10 (if YES, list specifications here): <br /> i <br /> COMMENTS: <br /> 'i <br /> i <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,Stale Laws,and Rules i <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, I shall employ persons subject to <br /> WORKERS'COMPENSATION Laws of Califomia." <br /> CALL THE VNIT IV INSPECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> ADV CeD <br /> Signed z cj;; 'V �A��� Title/Company WF6'iP�i�IS /inn�i..l 1✓12GAIiNP.+7'fif+C�T.UC.. r <br /> Print Name /BMi' l �II�FIG1�=� Date d7/Z1/off t1MW 1f-tS`{R�WhO11 1n�,? <br /> S -E- SITE,MAP' IN UNIT IV ,WORK PLAN_DA ED F23 T"J 'ZtSOD <br /> t' '/"�), � DEPARTMENT USE ONLY Q ��[[ ty i <br /> Application Accepted By Jam """-�_ Date Issued /��7'-tea Area Obs <br /> Grout Inspection By i' Date —Final Inspection By Dale <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: O ����� -�3•II�OI <br /> 7 I <br /> ACCOUNTING ONLY: AID# FArfi <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 2601 MvJ ' 14ob3 = 3D 0023989 <br /> 1/18/2000 <br />