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WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) f r, <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 Ft. ' <br /> (209r 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 and/Qr 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 Divisie <br /> 35560 Weld R d 33 y p gs3srs Parcew#)55-P60-G <br /> WELL Location oa Crass Street H/ Cit 1:PNA1.1S Zi <br /> i <br /> PROPERTY OwnerkM, eD ore,_ Q21l 1 o: AdddrCessli�l0 1l-D,11 k1AM Fee�yCay _T_Cka4 Zip 5�Phone# 1 8.3_ <br /> C-57Contractorc-irellDr:l� J <br /> T Co. /Address 1 O oWE R,:�. CityZip`}`I5S3 Lic#-f l/ SV5Phone# Sta 313- 58 <br /> onsulta t/Sub Contractorc'Ieor 10, r+' C Cons.1�..�t Address 2101 WebS+f-- 5-1'- CityOa�� Lic# Phone# 5'10-(063-431 <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> DNEW WEL /BORING CPT, GEOPROBE, HYO ROPUNCH, HAND-AUGER, OTHER-) DESTRUCTION (choose type belov <br /> 0 SOIL BORING# S 6 -`jam S d-JO, S L3- 11, S13- 1 a , 5$— 13 0 OVER-BORE <br /> WELL RESSURE GROU <br /> 'Other. �` <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 'HOLLOW STEM DIA. OF BOREHOLE 6 ;A. MULTIPLE CASINGS?o YES XIO WELL CASING DIA: tlG <br /> o EXTRACTION o AIR HAMMER/DRIVEN CASING THICKNESS 04A TYPE OF CASING: 0 STEEL o PVC IJ OTHER: <br /> 0 VAPOR o MUD ROTARY DEPTH OF GROUT SEAL-;u 4 baCK�41 TREMIE TYPE TO BE USED: AUGERS+*OS <br /> AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: YNW <br /> es p No (NOTE: MAXIMUM FREE-FALL DEPTH IS.3C <br /> `SOIL BORING HAND AUGER APPROX. BORING DEPTH 10' — -JO " 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> Q OTHER:_O OTHER CONDUCTOR CASING PROPOSED? t4A (it YES, list specifications here): <br /> COMMENTS ��'�1� J bor:n�S �i " d's•-nC�t'' ) lJ 1�n I�ol�ow �-12.r�► AJ3C„ . one_ bo ..meq 4o 70 <br /> one. Q ' alleCck' s0; <br /> NOTE: OFFSITE BORINGS REQUIR 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 Rule <br /> and Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: "1 certify that in the performance of the wor <br /> for which this permit Is issued,I shall not employ persons subject to WORKERS'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'COMPENSATION Laws of California." <br /> TH PLICANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed x Title 017.1fa1t <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED <br /> DEPARTMENT USE ONLY <br /> Application Accepted ByDate Issued S�//DZ <br /> e��L <br /> Grout Inspection By l"'r�^�n-f-t Date M7- <br /> OZ Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOIC <br /> /o0116 <br /> C 5:7 LCISED'CNTA;ETC�R„h }ST � N LICENSE:& C1RKECM) EIA, S DECIAk1TTQl <br /> UNIT IV- 6/23/99 /sign bkpg/MI <br />