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9-22-1999 A:00PM FROM r..3 <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 <br />(209) 468-3450 <br />NON-REFUNOABLE 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, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Serrviiccas, Environmental mentals Health Division. <br />WELL Location 3 011 W -Q GNA I Cross Street 5 City I OLtA/l ZP l J°t Parcel# <br />L O, g o x , 7 5 7G City Stock ruti_Zip Phone# <br />PROPERTY Owner L V CI Lfit t to Address <br />C-57 Contractor � A) l IYIq Address So ure R City ✓tl Zi <br />p`I`(5J` LiC# Ygs/� Phone# <br />-3f3 • ego a <br />CaVylbV 1 Address�� 6X a J«1 City �� Lac# Phones# 707-9$5- Y8'S 0 <br />Consultant 1 Sub Contractor_ <br />GIS Coordinates: X • Y <br />Township Range Section <br />,'SOIL BORING # I <br />7WELL# 4 <br />WORK TO BE PERFORMED <br />r sr <br />NEW WELL I BORING ( CPT, GEOPROSE. HYDROPUNCH. HAND AU ER, OTHER") <br />., p _'• <br />TYPE OF WELL <br />MONITORING <br />0 EXTRACTION <br />f] VAPOR <br />AIR SPARGE <br />Q SOIL BORING <br />J OTHER: <br />COMMENTS: <br />HOLLOW STEM <br />o AIR HAMMER/DRIVEN <br />Q MUD ROTARY <br />PUSH POINT <br />p HAND AUGER <br />L p DESTRUCTION (choose type below) <br />JJJ Q OVER -BORE <br />PRESSURE GROUT <br />CONSTRUCTION SPECIPI(.;A t 1UNil r <br />DIA. OF BOREHOLE— MULTIPLE CASINGS? 0 YES )'NO WELL CASING DIA: Sr <br />CASING THICKNESS SCk kO TYPE OF CASING: U STEEL XPVC Q OTHER: <br />DEPTH OF GROUT SEAL 6 r TREMIE TYPE TO BE USED: )(AUGERS CHOSE <br />GROUT SEAL PUMPED: 0 Yes C No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />APPROX. BORING DEPTH Jnr )(BOLTED TRAFFIC BOX or Q STOVE PIPE <br />CONDUCTOR CASING PROPOSED?N0 (if YES, list specifications here): <br />C <br />6 <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS! <br />the work will be done in accordance with San Joaquin County Ordinances. State laws, and Rules <br />I Hereby c®rtify that I have prepared this application and that <br />and Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: ' I certify that;n the performance of the work T <br />for which this permit ;s issued, I shall not employ persons subject to WORKMAN'S COMPENSATION Laws of ca/ifomia." Contractor's hiring or sub - <br />the work for which this permit is issued. 1 sholf employ persons subject to <br />contracting signature certifies the following: 'I certify that in the performance of <br />WORKMAN'S COMPENSATION Laws Of California.' <br />THE APPLICANT MUST CALL 48 HRS IN ADVANCES FOR ALL REQUIRED INSPECTIONS. <br />Title /� �rQ/e,CT zl�660grSTDatea1 " ZUIA <br />Signed x <br />SEE SITE MAP IN UNIT IV WORK PLAN DATED <br />DEPARTMENT USE ONLY rea 0 6e¢ <br />Date Issued / A <br />Application Accepted By ate <br />Date Final Inspection By <br />Grout Inspection By Ara <br />_ <br />Destruction Inspection By Date <br />r,nmmF'NTS / CONDITIONS: <br />ACCOUNTING ONLY: Al 09 <br />PE CODES FEE INFO AMOUNT REMITTED CHECK#1CASH <br />RECEIVED BY <br />OATS PER EST NUMBER INVOICE <br />6-2— iZ� 6l <br />3 6 <br />