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10--04-1999 10 = 32AM FROM P- 1 <br />WELL PERMIT APPLICATION FORM- UNIT IV <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) t <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <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 />L II-- I Assessor's <br />WELL Location 4 0 1 S 0 U tk L I n� 1,i S}, Cross Street (-hl UVCk .S City 40 C k t o hZip Parcel# / V 7- O L JO <br />- <br />PROPERTY Owner Ke V I h �A SS o Address 1 14' 5 W. Ck m vTuV WQ/City S�0 &1617 Zip � 9*20 V Phone# Z -011-4010-5112- <br />q <br />011- 4(010 •- 51 W 2- <br />Dvi11i✓i q5o liovde. R I Mvfiocz 94553 4$5i�o5 4Z5-313-5"boo <br />C-57 Contractor �TyGq 9 r1 Address 4 City Zip Lic# Phone# <br />Ices Po.3ox g928S e"^c'"y''iI � "30107Slo-X52-3z�� <br />Consultant / Sub Contractor Address City Lie# Phone# <br />GIS Coordinates: X , Y , Township Range Section <br />WORK TO BE PERFORMED <br />'NEW WELL f BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER') 0 DESTRUCTION (choose type below) <br />0 SOIL BORING # O OVER -BORE <br />,TWELL # M W - L--7 M W _ 2.- a PRESSURE GROUT <br />"Other: <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />2MONITORING 2 -HOLLOW STEM DIA. OF BOREHOLE � n MULTIPLE CASINGS? O YES O NO WELL CASINGDIA: ­t-I'� <br />0 EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />0 VAPOR <br />0 MUD ROTARY <br />0 AIR SPARGE <br />0 PUSH POINT <br />0 SOIL BORING <br />0 HAND AUGER <br />CASING THICKNESS TYPE OF CASING: O STEEL ,g'PVC O OTHER; <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS OHOSE�-- <br />GROUT SEAL PUMPED: 0 Yes p No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30� <br />APPROX. BORING DEPTH 25 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />0 OTHER: 0 OTHER CONDUCTOR CASING PROPOSED? <br />COMMENTS: <br />( if YES, list specifications here): <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 Ruses <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, t shall not employ persons subject to WORKERS' COMPENSATION Laws of California." Contractor's hiring or sub- <br />contracting signature certifies the following: "I ceRify that In the performance of the work for which this permit is issued, I shall employ persons subject to <br />WORKERS' COMPENSATION Laws of Calilomia." <br />THE <br />1E AAPPLICANT MUST CALL 48 WORKING HRS IN ADVANCEFOR ALL REQUIRED INSPECTIONS. <br />PV <br />Signed x 1 Title C-041( 1— Date <br />SEE SITE MAP VISV 4IN UNIT IV WORK PLAN DATED: 1111±11 <br />DEPARTMENT USE ONLY <br />Application Accepted By �Date Issued l/—I <br />Grout Inspection By �it/l�o�� Date F anal Inspection By rl�f.✓2 t Mw3 <br />Destruction Inspection By Date ( in�✓'f r K" <br />COMMENTS / CONDITIONS: �h <br />ACCOUNTING ONLY: <br />AID# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />HECK RECD BY <br />DATE PERMIT/ SERVICE REQUEST;9 <br />INVOICE <br />�i <br />yf <br />l [A18��! O <br />C-77 LICENSED CONTRACTOR MUST SIGN LICENSE &WORKERS' ' I LARATION <br />UNIT IV - 6/23/99 /sign bkpg/Ml <br />