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ROM : WILLIAM DUBOUSKY ENUIRONMENTAL PHONE NO. : 408 253 5026 P02 <br />WELL PERMIT APPLICATION FORM UNIT IV <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS»EHD) r) <br />RIGI UN <br />�� <br />304 E. Weber, Third Floor, Stockton, CA., 95202 v 1 y <br />(209Y 468-3449 <br />NON-REFUNDABLE P RMtT EXPIRES 1 YEAR FROM DATE ISSUED <br />k described. <br />Application is hereby made to San Joaquin County for a permit to construct andlgl install the WorThis apj>110 ion 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 2373 Mariposa iZoad CroseStreetF�i"IingtOnvity Stockton Zip <br />tJ5201 Parcelif-L71 300 9 <br />PROPERTY Owner111usky Crane Address 237:3 Mariposa Rdt;;ty StocktoniPQ.5201Phona#S.800 642-37 <br />C-57 Contractor H E W D r i 1_1_i i. n k; Address 1 Il /� 5 W P P k S t. —�CttYIWr�L.L�I fi 0 4 9 i$,7o*(b 5 V} 329-2851 <br />Consultant I Sub Contractor W i) E', A%FeS� �j R n � 9 9 ' _City r a dLc* U ( 6lhone#d(1-)-6,2-1-- 4 3 <br />GIS Coordinates. XY Township Range section <br />WQRK TO BE PERFORMED <br />x a KCW WELL I BORING (CP1, GEOPROI3E. HYDROPUNCH, HANG -AUGER, OTHER-) n DESTRUCTION (choose type below) <br />yowii, BORING M N o . 1 —_- — lI OVERBORE <br />d WELL PRESSURE: GROUT <br />t <br />*Other - — - <br />COMMENTS: <br />\- <br />TYPE OF WELL INSTALLATION TYPE_ 0,91 ME SPECIFICATIONS <br />DIA: <br />'\P <br />[j MONITORING DIA, OF BOREHOLE MUL'I IPLE CASINGS? a YES ONO WELL CASING _ <br />EXTRACTION [] AIR HAMMER/DRIVEN [;ASING THICKNESS ��_ TYPE Or CASING U STEEL 13 PVC 11 OTHER-_ <br />[] VAPOR [] MUD ROTARY DEPTH OF GKOU-1 SEAL ". TREMIE TYPE TO BE USED: [] AUGERS []HOSE <br />Q AIR SPARGE a PUSH POINT GROUT SEAL PUMPED. Q Yes Q No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />- <br />e,9Q64 W)RNG 0 HAND AUGER APPROX BORING DEPTH 0 BOLTED TRAFFIC BOX or 13 STOVE PIPE <br />D QTHER:T n OTHERCONDUCTOR CASING PROPOSE=D? (if YES. list specifications here): <br />_Jv <br />COMMENTS: <br />C <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br />1 hereby certify that I have prepared this application and that the work will be done In accordance with San Joaquin County Ordinances, State Law6. and Rules <br />f it I "/ t OR t t fh rf rmance of the wor* <br />and Regulations of the San Joaquin County. Homeowner or licensed agent s signature certifies the o ow ng. cert fy g n e pe o <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 />oontractinq signature certifies the following. 'I mortify that in the performanca of the work for which this permit is Issued. I shall employ persons subject to <br />WORKERS' COMPENS TION Laws of CalNornia " <br />T E APPLICANT UST CALL HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. �r <br />-� Sigrie / 2.. <br />f ��g1: �� Date 7/� 1 9 4 <br />Title <br />SEE SITE IN UNIT IV WORK PLAN DATED 7��°�4g <br />DEPARTMENT USE ONLY `� <br />Application AreapfP.d By ._ Date Issued / <br />Grout Inspection By , Date Final Inspection By fiats _ <br />Destruction Inspection By Date <br />COMMENTS I CONDITIONS: bb --�j <br />ACCOUNTING ONLY: I AID* <br />PE CODES I FEE INFO 1 AMOUNT REMITTED I CHECKSICASH <br />UNIT IV - 6/23/99 /sign bkpg/MI <br />FAC# <br />RECEIVED By I DATE I P <br />NUMBER I INVOIC <br />Wrl>-1 -1 t^.I\-0-, I -- P r-rR 1 -77- ' <br />