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WELL P5RMIT 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 FILE <br /> COPY <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIR=S 1 YEAR FROM DATE ISSUED <br /> Application iz hereby made to San Joaquin County for a permit to construct and/or install the work described This a?plication is made in comp:fiance with <br /> San Joaquin County gevelopment Title,Chapter 9-7'15 3 and the Standards of Sa-i Joaquin Ccunty Pub,Pc Health Services, Envircnrnentai Health Division. <br /> a! yu a/ ♦ 70 9-S 0 <br /> WELL Location 2701 N.4LofS�rJa y Cross Street •�0.�19+�"'l Cir;SO-il 'loK Z 7gs21 assessor's <br /> - �, _-�—_ _ Parcel# //7-O8ii <br /> PROPERTY Owner f}meoy-PRe.-I Tit Address Z.7Zt_IJ• PkX AZ Zir� <br /> [1 n p8f Phone;' <br /> C-57 Contractor GeZ40L 16":/Ill Aedress 9� HZII-fie- i�. City_ P��'�. Zlp +{SS Lim 85165 Phone#92S-3/3-x'00 <br /> Coe.sultar i Sub Contractor Address z.0z-6-F4rtr brl—C:tyPI'RX A4- Lic_ Phone�2-72$-0707 <br /> GIS Coordinates.X Y Township Rariye Section <br /> WORK TO BE PERFORMED <br /> (xNEVJ WELL r BORING(CPT,GEOPROBE,HYDROPUNCH.HAND-AUGER,OTHER') 0 DESTRUCTION(choose type mio'Nj <br /> 0 SOL.BORING# OVER-BORE <br /> J@ WELL# 5012Y-- ��I T4t� �PRESSURE GROUT <br /> 'Other:_ <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> rl <br /> ILMONITORING ;"HOLLOW STEM DIA.OF BOREHOLE 1C) n MULTIPLE CASINGS?X YES 0 NO WELL CASING DIA: 2• <br /> 0 EXTRACTION 0 AIR HAMMERlDRIVEN CASING THICKNESS_TYPE OF CASING: 0 STEEL XPVC Q OTHER <br /> o VAPOR 0 MUD ROTARY DEPTH OF GROUT SEALZS- `tri r TREMIE TYPE TO BE USED: AUGERS OHOSE <br /> a AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: ,KYes 0 No {NOTE: MAXIMUM FREE-FALL DEPTH IS 30'} <br /> 0 501'-BOP,ING 0 HAND AUGER APPROX.BORING DEPTH FCr )(BOLTED TRAFFIC BCX or 0 STOVE PIPE <br /> 0 OTHER_D OTHER CONDUCTOR CASING PROPOSED? Ne (if YES,list specifications here): <br /> COMMENTS: S2G aft f ►t�GV( � ed�a,'�Y �t, t " T b�� 3 <br /> r -- <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> hereby certify that I have prepared this application and that the work will be done in accordance with Sar Joaquin County Ordinances,State Laws,and Rules <br /> and Regulations of the San Joaquin County. Hcrreowner or licensed agents signature certifies the following: '7 certify that in the performance of the work <br /> for which this permit is issued, t shall not employ persons subject to WORKERS'COMPENSAr10 N Laws of California." Contractor's hiring or sub- <br /> contracting signature certifies the following: '7 certify that in the performance of the work for which this perrnit is issued, I shall employ persons subject to <br /> I,VORKERS'COMPENSATION Laws of California.' <br /> N# # 8 il�(t,}( liN 't 3RD+ t'�DE�+S1E 7sx . gAL�l)f � !E GTI E3S <br /> S good x ���Gt� Title '1�� Date �/Y <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED: &3 l9 'd i7f) <br /> DEPARTMENT USE ONLY O� ,.,f�<f/ <br /> App,ication Accepted By Date Issued _Area <br /> Grout Inspection By Date Final Inspection By Date__ <br /> Destnrction Inspection By Date <br /> COMMENTS/CONDITIONS: r0 rt/ 6Z( 00- <br /> e--ACCOUNTING ONLY: AID# FACOU <br /> #— <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# RFC'D SY DATE PERMIT/SERVICER UEST# INVOICE <br /> —309 <br /> Gw—�c jOi0 —100 <br /> L -- <br /> C �7 I�� T ETA:CON RAGTC�F.11 t1St. GN LTr EY a ,; RS 2? VSAT G U'£CLAR,A ION <br /> UNIT IV- 6/23/99/sign bkpg/MI <br /> Z d WObd WdLE V 6661-1� <br />