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a <br />WELL PERMIT APPLICATION FORM`11 <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICE 0/�00,00 <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 �S, `%� V <br />(209) 468-3449 C I <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED c� ` T� <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 />n J iilcv 1 Assessor's <br />WELL Location �_ LextA LcJ Cross Street 1 +s/,+s�r,c City y/4,;&, Zip Parcel# <br />i().., <br />PROPERTY Owner 4;,�i.,i /�!'s+ ;_;�e%r ^AdDdressl�56 F. Ah,IuJE�r_Clit/y C Zip 917& Phone# y 4'-S`+Cr i2Gi�r <br />C•57 Contractor V. �/ Ac>l, lA— Address / Lt. �sJG'Y 5/ City c U:_. ZipJy.S'7/ Lic#' "'�" Phone# 9/& 7'7'7- 49/60 <br />Consultant /Sub Contractor hj6r pc-'..�ienc�r Address f, b tSc'[ 1;9 City / �*/Licit Phone#)aG+�.19St <br />GIS Coordinates. X , Y , Township 5 Range, Jl� Section IL <br />WORK TO BE PERFORMED <br />V/NEW WELL / BORING (CRT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) 0 DESTRUCTION (choose type below) <br />0 S IL BORING # 0 OVER -BORE <br />04ELL # !J / Ira S Fy(/r ej q3 /Q Clracf p PRESSURE GROUT <br />'Other: <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />"ON17ORiNG R-'60LLOVV STEM DIA. OF BOREHOLE MULTIPLE CASINGS? 0 YES 6'NO WELL CASING DIA <br />0 EX TRACTION [j AIR HAMMIER/DRIVEN CASING THICKNESS Sia /D J5`%TYPE OF CASING: a STEEL 0'6VC 0 OTHER <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED. 0 AUGERS 6+16 -SE <br />0 AIR SPARGE [] PUSH POINT GROUT SEAL PUMPED: 0 Yes i3 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30) <br />0 SOIL BORING [)HAND AUGER APPROX BORING DEPTH .2©4' #tOLTED TRAFFIC BOX or 0 STOVE PIPE <br />0 OTHER:_U OTHER CONDUCTOR CASING PROPOSED? ( if YES, list specifications here) <br />COMMENT <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, t shall not employ persons subject to WORKERS' COMPENSATION Laws of California." Contractors hiring or sub- <br />contracting signature certifies the following: 'Y certify that in the performance of the work for which this permit is issued, l shall employ persons sub;ect to <br />WORKERS' COMPENSATION LaAs of California." <br />THE APPLICANT MUST CALL 48_ WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />Signed xWW y Zwv/' y/ Title Qk K-fiLucl-L/u Date 3. 1 _ <br />SEE SITE MAP IN UNIT IV WORK PLAN DATED: ���zi(ar'.r �t , y `! <br />DEPARTMENT USE ONLY -7 <br />Application Accepted By Date Issued �' 7 —,ry Area Q ;7S 6 <br />Grout Inspection By —Date /—, 'Y—VC) Final Inspection By Date <br />Destruction Inspection By l nate <br />ACCOUNTING ONLY: TxTrw <br />EA <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE P QUEST # INVOICE <br />C-57 LICENSED CONTRAGTOR''MUST SIGNI1,10ENSE &W,0PXERS - RATION <br />UNIT IV - 6/23/99 /sign bkpg/MI <br />