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9-09-1999 11:39AM FROM p 2 <br />WELL PERMIT APPLICATION FORM IV <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL <br />Thi dFloor,HEALTH <br />DIVISION (PHS-EHD) <br />30 E <br />4 Stockton, CA., 95202 �,p��� <br />(209 ) 68 3449 %F4i 000 <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 Go with <br />San Joaquin County Devolopment Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />WELL Location\3 b S k her R,0�. <br />Cross Street City S c a.�o 5 Assessor's <br />ti Zip 3 i0 Parcel# <br />PROPERTY <br />Owner <br />lz �rj ,� Address.? 7 t3 Cit,y(sSCkI o-Zlp S 320 <br />phone#_$3 � <br />/LC-S7ContractorLW 2AN\; � Address CityS'ct1 Zip(56$Lic# 110 67 <br />Phone# %b�i_1_7—V)0t7 <br />Consultant / Sub Contractor Address City Lic# Phone# <br />GIS Coordinates. X Y Township Range Section <br />WORK TO BE PERFORMED ` <br />XNEW WELL / BORING ( CPT, GEOPROSE, HYDROPUNCH, HAND -AUGER, OTHER") <br />0 SOIL BORING # <br />O WELL # 1^n s <br />'Other: <br />COMMENTS: <br />TYPE OF WELL <br />INSTALLATION TYPE <br />MONITORING <br />a HOLLOW STEM fns a <br />0 EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />0 VAPOR <br />I MUD ROTARYmw VD) <br />0 AIR SPARGE <br />0 PUSH POINT <br />0 SOIL BORING <br />0 HAND AUGER <br />0 OTHER:_ Il OTHER <br />0 DESTRUCTION (choose type below) <br />0 OVER -BORE <br />0 PRESSURE GROUT r J <br />V <br />DIA. OF BOREHOLE (5' " MULTIPLE CASINGS? 0 YES U NO WELL CASING DIA; <br />CASING THICKNESS OTYPE OF CASING 0 STEEL IIIPVC 0 OTHER: <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: I AUGERS DHOSE <br />GROUT SEAL PUMPED; 0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH 1S 30') <br />APPROX. BORING DEPTH "1 S I rhw V d- S U 80LTED TRAFFIC BOK or U STOVE PIPE <br />CONDUCTOR CASING PROP 05ED w 1.01 <br />nro( if YES, list specifications here): <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: "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 />WOPKCRS' COMPENSATION Laws of Caftmia. " <br />TH PLI ANT MUST WL 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS, <br />C <br />Signed x Title 0- S kA ��g,�Date_ i� JJ3 0 <br />SEE SITE MAP IN UNIT IV WORK PLAN DATED: <br />DEPARTMENT USE ONLY <br />Application Accepted By Date Issued I O r1 / O C� Area <br />Grout Inspection By �i� `�_ Date ° b—l`( pp <br />Final Insp®otion By,r o Dp Date <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # 7REC'D BY DATE PERMI ICE REQUE INVOICE <br />vI ,off (rj oO AR#Ooa,J ZI <br />C-57 LICENSED CONTRACTOR MUST SIGN LICENSE &W4� Mt'ENSA hATIC1IV <br />UNIT IV - 6/23/99 /sign bkpg/MI <br />