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9-22-1999 A:00PM FROM F -.s <br />ORIGINAL. <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 C) N <br />(209) 468-3450 <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 DevelopCme_nt-Titte, Chapter 9-t t 15.3 and the Standards of San Joaquin County Public Health Services, EnvironmentalAss eplth Divi <br />WELL Locationa4lq t � C wt Cross Street I (fit v t City St�Gk t"'W- Z P 9.Sa o - Parcel# <br />PROPERTY Owner C UI�P✓1 Eh it �C Address l l�0 Peg t)Qka12d City *4st! ,Zip776f6 Phone#5S9-6y5-`1306 <br />C-57 Contractor s ZVl itU Address Y5o PJ City JMAI'•fbyz Zip 1`l55 Lic# Sj� 067Phone-#Jct 313'Sl!��B�� <br />—� Phonerf707��3s"7a s© <br />Consultants Sub Contractor (AM i Q �b�y • AddressR,7� �Z�k�y�s 57. City SGUTAM Lic# <br />GIS Coordinates: X • Y <br />Township Range Section - <br />WORK TO BE PERFORMED ( I, <br />5 a DESTRUCTION (choose type below) I <br />JfNEW WELL/ BORING (CPT EOPROSE, HYDROPUNCH. HAND -AUGER, OTHER") a OVER -BORE -� <br />SOlL BORING # 513-,38J'� S6"f6r SB"U a PRESSURE GROUT -_r) <br />G WELL # <br />'Other: <br />C,IAMENTS: <br />fj MONITORING <br />G EXTRACTION <br />I] VAPOR <br />G AIR SPARGE <br />`SOIL BORING <br />G OTHER: <br />CONSTRUCTIUN IT et-- <br />HOLLOW <br />tHOLLOW STEM DIA. OF BOREHOLE a I MULTIPLE CASINGS? 0 YES )(NO WELL CASING DIA; <br />G AIR HAMMER/DRIVEN CASING THICKNESS —& -4 -4 TYPE OF CASING: G STEEL G PVC G OTHER: <br />a MUD ROYARY�-- — DEPTH OF GROUT SEAL TREN1tE TYPE TO 8E USED: n AUGERS CHOSE <br />PUSH POINT MPED: G, o NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />17 <br />a HAND AUGER APPROX. BORING DEPTH 9S 0 BOLTED TRAFFIC BOX or a STOVE PIPE i <br />CONDUCTOR CASING P POS /V)+ (if YES, list specifications here): <br />COMMENTS: <br />\I` NOTE: OFFSITE BORINGS RE UIRE A CESS OR ENCROACHMENT PERMITS! <br />I Hereby c®rtify that I have prepared this appfication 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: "1 certify that in the Performance of the work <br />for which this permit is issued, I shall not employ Persons subject to WORKMAN'S 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 shell employ persons subject to <br />WORKMAN'S COMPENSATION Laws of California_' <br />JOHE APP CANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />C <br />Signed)( tie ld/kr 13 <br />1 <br />_l <br />SEE SITE MAP IN UNIT IV WORKPLAN DATED <br />DEPARTMENT USE ONLY <br />Date Issued Area <br />Application Accepted By Date <br />Grout Inspection By Date Final Inspection By <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AIDS <br />PE COOES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK#JCASH <br />RECEIVED BY <br />GATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br />