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WELL PERMIT APPLICATION FORD UNIT IV <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD)NO V 0 9 2000 <br />304 E. Weber, Third Floor, Stockton, CA., 9520E�VIRONMEiNI" HcALTH <br />(209) 468-3449 PERMIT/SFRVICES <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 San <br />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 qZ3 �01117'9 MiAN-C / AEAr UE Cross Street WMeJ7 ST. City S766e-retl Zip 95S 26? Parcel# 1-37-236-&(l <br />CrAASE CgEVIZOL47 s7EY26 915- <br />PROPERTY Owner C/oJ;,.FFrAY SETALESS Address32G3 W. RZIOU1 LLWf City 576,&dtil Zip Phone# <br />C-57 ContractorFNVIIZOK-66C <br />Address 400.5 k( �JI456r•( vVA V City5Z'9WtWJ Zip S oS- Lic# Z27 Phone# y67 - (66b <br />Consultant/Sub Contractor <br />A(jr�- <br />Address SaM.dE City Lic# Phone# L%7 - lad(, <br />GIS Coordinates: X <br />Y <br />Township Range Section <br />CHECK # <br />RECP BY DATE P <br />WOR <br />K TO BE PERFORMED <br />i�,�­ L <br />V,NEW WELL / BORING <br />( CPT(nEOPROB <br />YDROPUNCH, HAND -AUGER, OTHER-) a DESTRUCTION (choose type below) <br />OIL BORING # 15R - 10.,I If 3, I4 a OVER -BORE <br />a -WELL # <br />0 PRESSURE GROUT <br />*Other: <br />COMMENTS: <br />TYPE OF WELL <br />INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />a MONITORING <br />a HOLLOW STEM <br />, /n <br />DIA. OF BOREHOLE -1- 5 MULTIPLE CASINGS? a YES gNO WELL CASING DIA: /�A <br />a EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />CASING THICKNESS N TYPE OF CASING: 0 STEEL a PVC a OTHER:Aj� <br />o VAPOR <br />a MUD ROTARY <br />DEPTH OF GROUT SEAL O ?S I TREMIE TYPE TO BE USED: 6,AUGERS BHOSE <br />p AIR SPARGE <br />X PUSH POINT <br />GROUT SEAL PUMPED: p Yes I(No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />`a SOIL BORING <br />a HAND AUGER <br />APPROX. BORING DEPTH ZD 3S r a BOLTED TRAFFIC BOX or a STOVE PIPE <br />a OTHER:_a <br />OTHER <br />CONDUCTOR CASING PROPOSED? Imo_ ( if YES, list specifications here): <br />COMMENTS: (4) 5014. -t�6i2 "(t 7,t Zoe (I) Sol -- b6P.JAt1r is ?5' AbL &AG(,LFILLQ, 76 <br />Sttfl-1=AGk- C:��� wi�7�1 PcsQ.rcA►•Ia ���nl% <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: `7 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: '7 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 Califomia." <br />U!"0114 ON <br />i <br />Signed x <br />Title ST4FF L'r&L6C,15"f Date L'S t4QLfM89e- Zeoa <br />SEE SITE MAP IN UNIT IV WORK PLAN DATED: <br />Application Accepted By_ <br />Grout Inspection By <br />Destruction Insoection Bxi <br />COMMENTS/ <br />,?EPARTMENT USE ONLY <br />lIy <br />Date Issued / i Area <br />Date inal Inspection By Date <br />Date <br />ACCOUNTING ONLY: <br />AID# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />RECP BY DATE P <br />UEST # <br />INVOICE <br />i�,�­ L <br />f�f <br />�� ti i/�u_' <br />CC2��'�J�` <br />UNIT IV - 6/23/99 /sign bkpg/MI <br />