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TYPE OF WELL <br />O MONITORING <br />El EXTRACTION <br />a VAPOR <br />U AIR <br />LNS)ALLATIONLLATION TYPE <br />tROLLOW STEM <br />I] AIR HAMMER/DRIVEN <br />fl MUD ROTARY <br />1:1 PUSH POINT <br />lvolL BORING A HAND AUGER <br />OTHERC-.'T 1613 0 OTHER <br />gLi IP <br />L vw., R.-- Date 7 <br />WELL PERMIT 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 <br />(209) 468-3449 <br />NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br />Application is hereby made to San Joaquin County for a permit to construct and/cii: install the work described. This application is made in compliance with <br />San Joa quin 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 560 ‹.CACIL/ r7224.3) A ST', Cross Street City cre2G-ICIDA 1ZiP/ 52n3 Parcel# <br />PROPERTY Owner Niga2tstipai,uouvAla,M 4s6 sc6TM T. City ST64POLI Zip_672,f2Phone# 466.47G3 <br />C-57 Contractor RUM Address ress 23 1, C 16.14Jpm Doilgity jAp_90e6-Lic# 57Z-Ze--4ne# <br />Consultant / Sub ContractorreeilliLL Et)4 1011446iss_12:71.3 .1+11)1) 024,17iy Lic#11/61 Phone#30-7g ( <br />GIS Coordinates: X Y Township Range Section <br />WORK TO BE PERFORMED <br />0 NEW WELL / BORING EOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') P1- 11 DESTRUCTION (choose type below) <br />U SOIL BORING # U OVER-BORE <br />0 vvELL # ij zrili___mmtrpLAIG. We (....LS. D PRESSURE GROUT <br />"Other: \J\-) _ <br />COMMENTS: <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE if, " MULTIPLE CASINGS? a YES a NO WELL CASING DIA:_ <br />CASING THICKNESS/-' • TYPE OF CASING: 0 STEEL 151 PVC Il OTHER:_______ <br />DEPTH OF GROUT SEAL 1- 2- 1 TREMIE TYPE TO BE USED: 11 AUGERS ---W--- )S -.E <br />GROUT SEAL PUMPED; a Yes a No (NOTE: „MAXIMUM FREE-FALL DEPTH IS 30') <br />APPROX. BORING DEPTH 3c ' 0.01.TED TRAFFIC BOX or p STOVE PIPE (--- <br />CONDUCTOR CASING PROPOSED?_AQ 0 ( if YES, list specifications here): 1:1:=' <br />is--- <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 Rulos <br />and Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: "I certify that in the performance of the work <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' CO iP NSATION L ,s of alifornia." <br />THE T MUS FALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIO S. <br />Signed x <br />SEE SITE MA IN UNIT IV WORK PLAN DATE 71,l 2f1 il <br /> <br />DEPARTMENT USE ONLY <br />Date Issued <br />Final Inspection By 7 -13 - <br />Application Accepted By Ct7.00-G--1--tA-t° <br />Grout Inspection By /ht, 7 4- Fri t,: d c/o-Date 7 <br />Destruction Inspection By <br />41(4.) 7 --c5de <br />COMMENTS / CONDITIONS -'1 10-W C-S / <br />„_,J,..____etz.11,"?-- <br />ACCOUNTING ONLY: AID# <br />FAC# <br /> <br />_ <br />PE CODES FEE INFO AMOUNT REMITTED RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE 6t/ CASH <br />'3 S-0 / 6 61 -- E? — 3'i L. C0 <br />C-57 LICENSED CONTR.ACTOR MUST SIGN LICENSE &WORKE <br />UNIT IV - 6/23/99 /sign bkpg,.—