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9-22-1999 4:00PM FROM 1-'- � <br />WELL PERMIT APPLICATION FORM UNIT IV <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ���l�ll v �U <br />ENVIRONMENTAL HEALTH DIVISION ("PHS-EHD") OCT 0 3 2002 <br />304 E- Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3450 ENVIRONMENT HEALTH <br />PERMIT/SERVICES <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 <br />Health Division. <br />_711C L�t,e,S,ac/,,e_� Fd•JCross Street 144City L P-c2sL- <br />Parcel# C) <br />WELL Location—.r . Cty <br />PROPERTY Owner Tk,VUCN)e1IrS_5L14,i <br />,Zip 9 S 40 Phone# <br />- (:S7 <br />C-57 Contractorz__C�QLLj �Address /I o ,JCJc <br />City t +�� Zip 7VS53 tic# i85�65 Phone# 575-3i_? o� <br />✓�pn <br />i^�-tJ ress 770 Perlc.rJ Sf%ri>YCity U�a� Lic# Phones# 707-133-2367 <br />Consultant i � r 6%, L'i ^ - <br />Y Township Range Section C) <br />GIS Coordinates: X — <br />G <br />WORK TO BE PERFORMED <br />type below) <br />(] NEW WELL /BORING (CPT, <br />DESTRUCTION (choose <br />GEOPR06E, HYDROPUNCH. HAND AUGER, OTHER") p DQ OVER -BORE <br />aSOIL BORING # B- <br />3� 8 - 0 PRESSURE GROUT <br />C <br />WELL 9 <br />'Other: <br />CCM. MENTS: <br />TYPE OF yyELL <br />CONSTRUCTION TYPE <br />CONSTRUCTION SPECIFICATIONS <br />Z MULTIPLE CASINGS? 0 YES ONO WELL CASING DIA; <br />ij MONITORING <br />0 HOLLOW STEM <br />0 AIR HAMMERIDRIVEN <br />DIA. OF BOREHOLE <br />TYPE OF CASING: p STEEL 0 PV G OTHER _rv� <br />CASING THICKNESS__ &. ftp <br />0 EXTRACTION <br />I] VAPOR <br />0 MUD ROTARY <br />DEPTH OF GROUT SEAL 3 S TREMIE TYPE TO BE USED: 6A4G_i rr 0 HOSE <br />MAXIMUM FREE -FALL DEPTH IS 30') <br />0 AIR SPARGE <br />pj PUSH POINT <br />GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: <br />APPROX. BORING DEPTH 3 S r 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />SOIL BORING <br />0 OTHER:_(ze. <br />D HAND AUGER� <br />or _ <br />CONDUCTOR CASING PROPOSED? (if YES, list specifications here): _ <br />COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS! <br />I hereby certify that 1 have prepared this aPP!Ication 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 smp/oy persons subject to <br />WORKMAN'S COMPENSATION LawS of Celif0mia." <br />TH�-QPPLICANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />Title(- <br />Signed <br />itl Signed x_ `� - <br />SEE SITE MAP IN UNIT IV WORK PLAN DATED Ii rlDz - <br />DEPARTMENT USE ONLY <br />Date Issued Area <br />Application Accepted By L 1^ <br />Grout Inspection By L�(Zr�'s ^r' � <br />Date O Z Final Inspection By Date O <br />Destruction Inspection By Date <br />I f / l - rl'1 I __ I I ,, _ 4 -A,- ,4' A( /ww )A4 <br />ACCOUNTING ONLY: AIDS <br />PE CODES FEE INFO AMOUNT REMITTED CHECKWCASH RECEIVED BY GATE PERMIT/SgRVICE_REQUEST NUMBER INVOICE <br />�,0 I E `iZ ��� f y c' 3 <br />3Sol � �`�• <br />