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WELL PERMIT APPLICATION FORM , UNIT IV <br />I <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVIC S,- I .d ' I <br />ENVIRONMENTAL HEALTH DIVISION ("PHS-EHD") JUN 241999 <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3450 <br />ENVIRONMENTAL HEALTH <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERM I SERVICES <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 Services, Environmental Health Division. <br />Assessor's <br />WELL Location i9 Z M F F A T 13 L VD Cross Street S14F S14RM AN AV. City MA N ?EGA Zip .95-336 Parcel# 12 I- C 3 o p <br />SAN .fcAG,V,w CcJ;N-iy <br />PROPERTY Owner F A C i L I T I E S I`'1fi-Mr. QEPT. Address l}22 E.SCcTFJ FAV) City STccr('rC1J Zip9SZCS Phone#Zc:a-�t;E-3357- <br />VA LLE`f <br />C-57 Contractor FISCH E(4V. Address 3-)-J -'NfR%'S PLA Lr CitySPRWL-S Zip 95151-Lic#b`3?C.5Phone#-LC9-132-35'je <br />RANcItQ R.Cr- <br />ConsultantISub Contractor- CAlyAG-E ENV. Address P C, 13 CA ? City ImyitIErA Lic#5856 Phone#3t6 3S'J-325c <br />GIS Coordinates: <br />WORK TO BE PERFORMED <br />Township <br />Range Section <br />NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) 0 DESTRUCTION (choose type below) <br />0 SOIL BORING # H i 21 3, �? S; 9, I C I I 0 OVER -BORE <br />0 WELL # 0 PRESSURE GROUT <br />`Other: <br />COMMENTS: £ C-Fuf f,cOE Bcr-Im%�4 rN CI; E (A C,AiCUCrv,71,AL Cr, MM ISSiCNIFF ICE <br />TYPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS (� , <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE Z -IN MULTIPLE CASINGS? 0 YES I NO WELL CASING DIA: NA \ �' <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS N A TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: IJ A <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL t5" F F F r` TREMIE TYPE TO BE USED: 0 AUGERS (HOSE <br />0 AIR SPARGE I PUSH POINT GROUT SEAL PUMPED: 0 Yes I No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH 2 5- F I 'E T- 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />OTHER: &E G f' P G 5 E CONDUCTOR CASING PROPOSED? C ( if YES, list specifications here): <br />COMMENTS: Scc'Pr c wLFK OF TA1L-1=4 IN 11AMA�-E FNvIII IENTAi-'s WoRk r L A N <br />Dry <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 WORKMAN'S 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 />WORKMAN'S COMPENSATION Laws i rnia <br />THE APPLIQrANT M ST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTI NS. <br />Signed x— Title%V�Date <br />SEE `SITE MAP IN UNIT IV WORK PLAN. DATED <br />DEPARTMENT USE ONLY <br />Application Accepted By i A vim.- Date Issued G Z5 ^� Area <br />7— <br />Grout Inspection By Date `t; Final Inspection By �-LAndCo,, Date <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY. <br />FAC# <br />AID# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK#/CASH <br />RECEIVED BY <br />DATE <br />PE UMBER <br />INVOICE <br />35c1 <br />0 °�(� <br />UNIT IV - 6/1/99 /sign bkpg/MI <br />