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WELL PERMIT APPLICATION FORM ��FM 7 , ,T v� <br />kUrJr�E3d X1. MEAL1II �l r <br />.. <br />`r p1-FM.JT CFRVICF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES JAN 1 4 2002 <br />02 FEB- I I'll 1: 41 ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 9520 ETTL -RYAN ) <br />(209) 468-3449 GENERAL CONTACTORS <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 Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />// II Assessor's <br />WELL Location'? 3 7 rt • M t hCr' � Cross Street Ca (� rorrio. City 5+04, �'a n Zip 962-9 Z Parcel# t 39 2 q0 - 17 <br />3788 C-1kGnOve (31vr�• <br />PROPERTY Owner Uy%a ca) �or(�oc�o�ar+ Address %Ia%wy 3 5.+1;ry is City Elk am,- - Zip 5562 Phone# 4W 71'4 - 31-95 <br />C-57 ContractorlN04Ju-,0CJ Address pORjQK336 CityRioU►Si+>. Zip 1`1671Lic#?10071 Phone#V7-37`1-y300 <br />Dav,d er-so -7241 Phone#9I6 -631- 1300 <br />Consultant/ Sub Contractor („r.41er- j�„_Address3l-1V GuIJ17bCityRa,�cl,o�ar�lic# <br />GIS Coordinates: X , Y , Township Range Section <br />WORK TO BE PERFORMED <br />NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br />0 SOIL BORING # 0 OVER -BORE <br />NELL # 5? - 1 C SP - 3 C- 0 PRESSURE GROUT <br />'Other: � <br />COMMENTS: I'A <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />4.MONITORING NCHOLLOW STEM DIA. OF BOREHOLE 3 " MULTIPLE CASINGS? 0 YES ;10 WELL CASING DIA: ! y <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS 5c�% L/0 TYPE OF CASING: 0 STEEL )KPVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 40, TREMIE TYPE TO BE USED: 0 AUGERS 70OSE <br />-O-A+R SPARGE OZONE 0 PUSH POINT GROUT SEAL PUMPED: Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH %�- LABOLTED TRAFFIC BOX or 0 STOVE PIPE <br />0 OTHER:_O OTHER CONDUCTOR CASING PROPOSED? i./0 ( if YES, list specifications here): <br />COMMENTS: <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 />WORKERS' COMPENSATION Laws of California. " <br />T AP LICANT MUST CALL 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />Title `�/�or �eo�oci5� Date I�31�OZ <br />Signed X °- <br />SEE SITE MAP IN UNIT IV WORK PLAN DATED: 1112-7IC <br />DEPARTMENT USE ONLY <br />Application Accepted By Date Issued 7 <br />� . �- � i � � � Area � <br />7 Date `} It Final Inspection By Date ' � d <br />Grout Inspection By <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS <br />ACCOUNTING ONLY <br />PE CODES I FEE INFO <br />AID# <br />AMOUNT REMITTED I CHECK # I RECD BY I DATE <br />C-57 LICENSED CONTRACTOR MUST SIGN LICENSE &WO <br />UNIT IV - 6/23/99 /sign bkpg/MI <br />PERMIT I SERVICE REQUEST It I INVOICE <br />ECLARATION <br />Rn 2�82Z <br />