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WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES IRECEFV E EE <br /> ENVIRONMENTAL HEALTH DIVISION ("PHS-EHD") NOV 2 8 2000 <br /> 304 E Weber, Third Floor, Stockton, CA , 95202 <br /> (209) 468-3450 ENVIRONMENT HEALTH <br />' NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT/SERVICES <br /> Application is hereby made to San Joaquin County for a permit to construct andlor 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 /> C,G V W T`( CC V RT 1-t O U S EAssessor s <br /> WELL.Location 2Z2 E A ST W E 6 In R AV E Cross Street SA" -TC A QVI HCity ST C C(r,10 K Zip 9;LC Z Parcel# <br /> 5ANTOAQVIN COVNT s F-FT City D� C zip9y20 Phone# 209-4b?- 357F <br />' PROPERTY Owner AV411 (TM Address 1 c72 E 5 C0�[y UA LLIE Y G-� .f <br /> C-57 Contractor �t s G IA E ty Address 3 9y 51�E R 1'S >rAi City S PRt t3 Cr- Zip95. 2j 1 Lic#b CSPhone#7n4"112'3 }G <br /> RA1tG00 iz G <br /> Consultant f Sub Contractor R-A M A C-E NV Address P 0, 0X $ b_9City MV ii I C I A Lic# $!;6 Phone# 916-354 3 IS C <br /> GIS Coordinates X ,Y Township Range Section <br />' WORK TO BE PERFORMED <br /> NEW WELL I BORING(CPT,GEOPROBE HYDROPUNCH,HAND AUGER OTHER') Q DESTRUCTION(choose type below) <br /> Q OVER-BORE <br /> SOIL BORING# 4 L 3 [] PRESSURE GROUT <br />' p WELL# <br /> 'Other <br /> COMMENTS <br /> TYPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING ©HOLLOW STEM DIA OF BOREHOLE 11-114 MULTIPLE CASINGS?a YES I NO WELL CASING DIA KA <br /> EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS NA TYPE OF CASING []STEEL I1 PVC Il OTHER NA <br /> p VAPOR p MUD ROTARY DEPTH OF GROUT SEAL 25rT TREMIE TYPE TO BE USED p AUGERS MHOSE <br /> p AIR SPARGE PUSH POINT GROUT SEAL PUMPED Q Yes l No (NOTE MAXIMUM FREE-FALL DEPTH IS 30) <br />' Y,5— 1=T 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> �SOIL BORING [] HAND AUGER APPROX BORING DEPTH <br /> I OTHER C- C r R 0 B E CONDUCTOR CASING PROPOSED? N C (it YES list specifications here) <br /> COMMENTS SCOPE OF WO K QeCA1Cir4 tK RAVAh �NViRalalM�N >>l 'S WORk LRt� <br /> ATE IP TV L'� I t ZC C 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 agent s signature certifies the following "l certify that in the performance of the work <br /> for whfch this permit is issued, I shall not employ persons subject to WORKMAN'S COMPENSATION Laws of California" Contractor s hiring or sub- <br /> contracting signature certifies the fallowing "I cer+ify that in the performance of 079 work for which this permit is issued I shall employ persons subject to <br /> WORKMAN S COMPENSATION Laws Of Calrfomra <br /> THE APPLICANT MU T CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS <br /> -- <br />' Signed x <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED TVLY k4 1000 <br />' DEPARTMENT USE ONLY d // � f <br /> '� Areae�}' <br /> Application Accepted By Rate issueDate <br /> Grout Inspection By Date Final Inspection By . <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS <br /> # <br /> ACCOUNTING ONLY AID# <br /> PE CODES FEE INFO AMOUNT REMITTED �GC LICAS REjE <br /> E PERMITISERVICEREQUEST NUMBER INVOICE <br /> 3SU1 <br /> MITT TV- III/4q /sion bkpg/MI <br />