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WELLWERMIT APPLICATION F ZM UNIT IV <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <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 Develop,nent Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division <br />WELL Location 777 7 Lu I Imo --S 7rr� Cross Street(I r r fttyiw� City Zi %6 Assessor's <br />II � "" P 153 Parcel#�Af 13� - <br />PROPERTY Ownerl?,GdWtVI'T- � uw rv�, Address S7))rLO(C! r'�N <br />C-57 Contractor CAL -NA✓ EX �o`p u 1 / City ZiP r��hone# S'.2. 5 <br />AAddress y Hwt 7 r, �A Cit Sn.�. p c#-.?..FZ,S phone# Pvq 75:� S <br />/� ---� � Y Z � � Li o '77 <br />Consultant /Eab-e-c ratter r ��uw,,y�y�Gs Address ��� Ji v��f-- <br />C�ty'/I�-� Phoned SZ) J �J AL2 <br />GIS Coordinates: X_/ 7 3 9 G,2� y ,yyZ �A S— Township_.7t % <br />t � � Range 4 S � Section_ "Z - <br />WORK TO BE PERFORMED <br />C NC`A' VLCLL / BORING <br />(CPT. GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) <br />0 SOIL BORING # <br />DESTRUCTION (choose type below) <br />0 WELL # <br />!ti <br />XOVER-BORE <br />-�� <br />COMMENTS <br />, e c <br />S F u y c O PRESSURE GROUT <br />t <br />v <br />TYPE OF WEL <br />MONITORING <br />INSTALLATION TYPE <br />HOLLOW <br />CONSTRUCTION SPECIFICATIONS <br />0 EXTRACTION <br />0 STEM <br />0 AIR HAMMER/DRIVEN <br />DIA. OF BOREHOLE6 MULTIPLE CASINGS? 0 YES )KNO WELL CASING DIA: -'Ia <br />0 VAPOR <br />0 MUD ROTARY <br />CASING THICKNES,99 <br />—JYU--- TYPE OF CASING: 0 STEEL �,'I'VC 0 OTHER: <br />0 AIR SPARGE <br />0 PUSH POINT <br />DEPTH OF GROUT SEAL TREMiE TYPE TO BE USED D AUGERS <br />GROUT SEAL PUMPED: <br />0 SOIL BORING <br />0 HAND AUGER <br />Yes <br />0 p No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />IS 30' <br />0 OTHER:_ <br />OTHER <br />APPROX. BORING DEPTH D 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />.0 <br />CONDUCTOR CASING PROPOSED?~� <br />(if YES, list specifications here): <br />—4� <br />COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCRGACHMENT 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 V 4 <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 Califomia. - <br />THE APPLICANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />Signed x/►�. Q' <br />� <br />TiU�// /1AP/f /.� �c,t/� Date__ zN <br />9 /%jp p --y <br />EE 2�� /* <br />ITE MAP IN UNIT IV WORK PLAN DATED <br />DEPARTMENT USE ONLY <br />Application Accepted By �� �.,, Q � � Date Issued �02�/ 2 l� `/ <br />Grout Inspection By Area d 7 3-1. <br />Date Final Inspection By <br />Destruction Inspection By J Date <br />Date /.2 - a -O _ g <br />:.OMMENTS / CONDITIONS: ge if <br />ACCOUNTING ONLY: AID# <br />P:EC ODES FEE INFO AMOUNT REMITTED H C #/CASH <br />AC# <br />RECEIVED BY I DATE <br />io'p— I ( 0 ("v 2L, y y e-0 �// <br />C-57 LICENSED CONTRACTOR MUST SIGN LICENSE &WORKERS' <br />'NIT IV - 6/23/99 /sign bkpg/MI <br />PERMIT/SERVIC QUEST NUMBER INVOICE <br />SR# p°�lyy� <br />DECLARATION <br />