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jjrr��✓ �`,E: <br /> 'i'–GS-21300 8 03A i=RCM P. <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> i# SAN JOAQUIN COUNTY PUBLIC HEALTH SVERVICES <br /> i <br /> rF ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) '- <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 488-3449 <br /> NON•REF NDABLE PERMIT QNRI S j YEAR FROM OATS I SUED <br /> App4c,61i66 is hereby made to San Joaquin County for ti permit to eonstnsot anellar install the work dWriW� Thlp pppli0ytion Ir,rustle in o9mPliance with <br /> 3sn iaaquin County Development Title.Chapter 9-11'1$,3 and the Staindards df San Joaquin County Public Health Sanliee#, Envirgnrrantai Health Division. <br /> ' `,���/ ! ` �. A55�5sof's <br /> WELL Location `/ 1�/. .� .. . Cross Street City Zip Parcel# <br /> PKUPM- TY owner W/C•L.12,X Q . �r_reAoaresst6d daaa_t4 i- Vilijr n�r..4' _zip ,3..0ncnao_a.4..* .1.14 Y <br /> C•57 Contractor 16/?.!lIf?�S .16,)t/ Address J� i 7 •n e !L7/4 061ky122 <br /> Consultant!Sub ContractorrAddress )f /1e c CitY�.ic#-66Phonest`I/S�7Ya• °/�',,1' <br /> GIS Coordinates:X Yom,Township" Range Section —_ <br /> ' WORK TO BE PERFORMED �- <br /> i a NEW WELL!BORINGS(OPT,GEOPROSE, HYDROPUNCH,'HAND-AUGEK,OYNCR") ,DESTRUCTION(choose type below) <br /> a SOIL BORING# a OVERBORE <br /> a WELL PRESSURS GROUT <br /> + COMMENTS: <br /> TYPE OF WELL INSI•ALLATION TYP5 CONSTRUCTION SPECIFICATIONS <br /> 11 <br /> XMtONITORING a 1-1040W STEM DtA.OF BOREHOLE MULTIPLE CASINGS?a YES ONO WELL CASING 171,x:/ <br /> a EXTRACTION 11 Alii HAMMEWDRIVEN CASING THICKNESS A, /UA TYPE OF CASING: a STEEL a PVC a OTHER: T <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SdAL IIX TREMIE TYPE TO BE USED: a AUGERS CHOSE. <br /> „J p AIR SPARGE Q PVSM POINT GROUT SEAL PUMPED: ryes a No (NOTE' MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING a HAND AUGER APPROX. $ORING 012PTH-ALWBOLTED TRAFFIC 5OX of a STOVE PIPE <br /> a OTHER: a OTHER CONDUCTOR CASING PROP08i 0? (if YES. list specifications here): _ <br /> t. <br /> COMMENTS: <br /> n <br /> NOTE: OFFSITE BORINGS REQUIRE Accu5 OR ENCROACHMENT PERMITS <br /> I hereby certify that I have prepared this application and that the work will be done in sCcofel>ance with San Joaquin ZjouAty Ordinances, State Laws, and Rules, <br /> and Regulations of the S7n Joaquin County. Homeowner or licensed agent's signature certifies the following: "1 certify that In tho performance of the work <br /> f for which rhis permit is Issued,I snal!not employ persons jukiect to WORKERS'COMPENSATioN Laws of Callfornla," Contractor's hiring or s uo- <br /> ` contrectin signature certifies the following; 1 cert! #7art in.th m rlb+rrrorwr ofthe work for which this emelt is lssued, /shall employ 9 rg q. fY P pa G P Y Parsons subject to <br /> WORKE=RS'COMPENSAriON Laws ofCa1lfomie I' <br /> fi SHE kPP( .�i4trIT:I I 'G $11frc IW IRS`f `i Eiv], N �f© ►L RFI,�EXI�i Q IiVS ` C'!'ION . <br /> Signed <br /> X. , c,..�21 f ---- �_��_Title - ra�s7` Date_.'-� --•....... <br /> SEE SITE MAP IN UNIT 1V WORK : PLAN DATED: <br /> DEPARTMENT USE ONLY <br /> Rpptiovtioln Accepted By, L L• i. Date Issued Area <br /> Grout Inspection By Data Final Inti->o6on.Ry bate <br /> Desuuetion Inspection By Date <br /> COMMENTS l CONDITIONS: <br /> ACCOUNTING ONLY: Allprs <br /> +ki <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# - REC'D 6Y DATE PEitfi?IIT.I S>=RVIQE Rt=QUEST# INVOICE <br /> f r <br /> 37 p &g. Q 4 i� 1.�. 3 O C 7-7- <br />` i !`,�•7 1 YT1w�TCx Cti.I .f 11Wt'1.t7� 'f` i #?,,.11%1"i 1l`f+7<T'Y T["`F7L":'4*5711U TIi3•�irt�14A OaCrITC��' at' e►'•r:riitia 'i.r, n•,t.�. <br />