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�l =05-2000 8:0 2AI l FRO P. 2 <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> Weber, Third Floor Stockton CA. 95202 <br /> 304 E. We ., , <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 andlbr install the work described. This applioation is made in compliance with <br /> San Joaquin County Development Title Chapter 9-1115.3 and the Standards of San Joaquin County PubEic Health Services, Environmental Health Division <br /> Assessor's <br /> WELL location Cross Street -City. Zip Parcel# <br /> 3 <br /> PROPERTY Owner Wo 17,1,e Hf!ne I'U_ _Address PO nDr� Pz i'/ -City And e.s 1`0_ Zip 3 ,61 h one* :F-0 09 x <br /> ` �.!' n t° vel�o�G�� �} �,ny,, :.ZI ����[_A1C# Q0�r hOf1EL�/� 'Si'�- <br /> C-57 Contractor Jtk / Address �.__ tY 1�Jr P /� <br /> Consultant I Sub Contractor �c-el� l � )rf ✓ Address 1'rj 7 -'-�C V�f�/4�,Cr-City J 1,iG# 6_(1 Phone*`f/6 7rr 565 <br /> GIS Coordinates:X Y ..Township Range. Section <br /> WORK TO BE PZ_RFORM15D <br /> 0 NEW WELL I BORING(CPT,GEOPROBE, HYDROPUNCH,HAND-AUGER,OTHER") ) -DESTRUCTION(choose type beEow) <br /> p SOIL BORING# 0 OVER-BORE <br /> p WELL# `, PRESSURE GROUT <br /> 'Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> .'XMONITORING C HOLLOW STEM DIA.OF BOREHOLE MULTIPLE.CASINGS?0 YES a NO WELL CASING DIAD <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC- 0 OTHER: <br /> C VAPOR a MUD ROTARY DEPTH OF GROUT SEAL 114 TREMIE TYPE TO BE USED: 0 AUGERS CHOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 'OYes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> DSO I IL BORING 0 HAND AUGER APPROX. BORING DEPTH ,9 V, 0 BOLTED TRAFFIC BOX or C STOVE PIPE <br /> 0 OTHER'_G OTHERAvn CONDUCTOR CASING'PROPOSED? (if YES, list specifications hare): _ <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#ollowing: "1 certify that In the performance of the work <br /> for which this permit is issued,1 shelf not employ persons subject to WORXERS'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'COMPENSA TION Laws of Calffomra <br /> i tkE;APF'I YCAf�1T;IV�LJS`['. A4448..WCtRF 1NG HRS'04)�R11 N E FQ ;ALL ftEC1l .. )N AECTfONS <br /> Signed x Titl9 ,�rt �` Date <br /> 2.-/ -00 <br /> SEE SITE MAP 'IN UNIT IV WORK :-PLAN DATED: <br /> DEPARTMENT USE ONLY <br /> Application Accepted 13y_ [ v17 n Yat�nn�Ot L- -- - -- Date Issued3 I21� Area <br /> Grout Inspection By Date Final Inspection By Elate <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONDITIONS: --- --------- - <br /> ACCOUNTING ONLY; AID# <br /> PE CODES PCE iNFO AMOUNT REMITTED,. CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 3soz. D-oo 19C Z oD 007-Z_OZE0 <br /> GN 10ENSE W . '`�iC3M ENSA`1'�ON,DEG 4 TION <br /> VNZT IV- 6/23/99/sign bkpg/MI <br /> ii <br />