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k - F <br /> f <br /> g T' WELL PERMIT APPLICATION FORM UNIT IV <br /> i't{ _}.IRI( J Kl. �]ES-LI1 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 02 PEAR 19 AM 9' 41 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209),468-3449 <br /> I. NON-REFUNDABLE PERMIT EXPIRES 7 YEAR FROM DATE ISSUED <br /> Application 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 /> � � " Assessor's <br /> WELL Location /30 S• 0,15&0 w - Cross Street W45kilkl VA City 5h0L rpy� Zip�.SZbS Parcel# <br /> --�— <br /> /� p 5 gSVPhone# S1aY/ <br /> PROPERTY Owner 4 (� Address t�0. �9 _CityZip l� <br /> a ,f t 737— <br /> C <br /> Op <br /> C-57 Contractor 4&06W A rrd Address 1?D. Qv9C 35b city Rie uu,6�ZipTS71 Lic# 1�r Phones <br /> {�_ c 3 3d Caw► M ro, �6 <br /> Consultant/Sub Contractor )Ok V$- GN�1 i(•W�- • Address + �. �SSd City �r'1<- Lic#_1S �- Phone#/S30 676'�� <br /> GIS Coordinates:X Y Township Range Section <br /> t WORK TO BE PERFORMED <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) 0 DESTRUCTION(choose type below) <br /> 9 SOIL BORING# 0 OVER-BORE <br /> WELL# I W -I 7 l w - p PRESSURE GROUT <br /> i <br /> *Other: <br /> COMMENTS: <br /> F TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> p MONITORING HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?Q YES ?kNO WELL CASING DIA: / <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS Sc6t. q0 - TYPE OF CASING: 0 STEEL 9PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL -50 TRE•MIE TYPE TO BE USED: UGERS *OSE i <br /> F, 1�AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED:)KYes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING o HAND AUGER APPROX.BORING DEPTH 55 ' BOLTED TRAFFIC BOX or a STOVEPIPE <br /> t. p OTHER: a OTHER CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> t <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 following: '7 certify that in the performance of the work <br /> for which this permit is issued,1 shall not employ persons subject to WORKERS'COMPENSATION laws of California." Contractor's hiring or sub- <br /> contracting signature certifies the following: 1 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 California." _ 4 <br /> 'El l �' •� •� Tom' YfA. 'j�rr ��{ ].\f1 .� ... y 1 t... .:«.W i»y�.N�1��ji?:�0-M a �' M•'Y' I 'it L iz <br /> ..=..—. e..-.-. E��. ���._ Ali Ry : �' .l�^-��--�j <br /> Signed x t7 Title �� Date_ Z <br /> SEE SITE MAP IN UNIT 1V WORK PLAN DATED: <br /> yp DEPARTMENT USE ONLY ^� <br /> Application Accepted By . ea [r Date Issued -D"1/ O Area d-- <br /> Grout Inspection By Date Final Inspection By T Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FACO <br /> F <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK,# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 3 5 0 1 `� 18n 34q S IPf <br /> -1 Wiz po'gov <br /> UNIT IV-6/23/99/sign bkpg/MI <br /> Z 1 H08A HVVS: LL 6661-60—ZL <br />