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1-28-2000 2:41PM FROM P.3 <br />WELL PERMIT APPLICATION FORM UNIT IV <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES W�)K <br />%ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) / <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 ORIGINAL <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/or install the work described. This application is made in compliance with <br />San Joaquin -County Development Title, Ch ter�1315.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />O r�c,(,�` "f�(, �{/ Assessor' <br />WELL Location al CA0 Na 0r—Cross Street ,�w�f S} • City ! �te� •r Zip 9sc8d Parcel# 1�2���,,v�� <br />PROPERTY Owner lir. �+ I� f► �0c✓�^s Address ^(XJt I&a-d City f ko--fsvI Zip f&6 Phone#�SZ5S7"" <br />C-57 Contracto''&11 1%N Lo. Address 10 6.x 32 •C City Co (Ps Zipljr7f _Lic# 07 Phone#7d 7 371V Y3eo <br />Consultant/ Sub Contractor l'ty�'� .M �.s£ Address 10,1(S �oc�,�w..�C"ity hr-+ Lic# Phone# <br />GIS Coordinates: X Y Township Range Section <br />WORK TO BE PERFORMED Q <br />0 NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER') tDESTRUCTION (choose type below) <br />0 SOIL BORING # 0 OVER -BORE <br />I 0 WELL # 0 PRESSURE GROUT <br />'Other: W '}0 9e �esS✓^e v .� ce• a �.•� i-5. w -e S or.�s-Sac1 13 / <br />0 he w e (l -Fo <br />COMMENTS: <br />ae • ..e •. t e -+e <br />'f oi�.[` d eP <br />TYPE OF WELL <br />INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS <br />)CUONITORING <br />0 HOLLOW STEM <br />DIA. OF BOREHOLE `�. MULTIPLE CASINGS? 0 YES )^NO WELL CASING DIA:q <br />0 EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />CASING THICKNESS 0.)-%, TYPE OF CASING: 0 STEEL ArPVC 0 OTHER: <br />0 VAPOR <br />0 MUD ROTARY <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 9HOSE <br />0 AIR SPARGE <br />0 PUSH POINT <br />GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING <br />0 HAND AUGER <br />APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />0 OTHER: <br />0 OTHER <br />CONDUCTOR CASING PROPOSED? (if YES, list specifications here): <br />COMMENTS: wt % 2 -b " �s r►r � <br />be p <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,/ 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 />CALL HNIT I SPECTOR 48 WORKING HRS>IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />_ , /f n <br />Signed x Title/Company At g, oGltl' C 6 co /e -Ti S <br />Date /✓ ZG , <br />Print Name :x,•--..-._. a>a <br />DEPARTMENT USE ONLY <br />Application Accepted By Date Issued �O Area <br />Grout Inspection By Date Final Inspection By r J-MT"�+� Date <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: f <br />ACCOUNTING ONLY: 7AID# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PER ST # <br />INVOICE <br />35o2- <br />a w <br />sR#002 411 <br />