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03i'17/2000 14:31 2094683433 FIFTH FLOOR I`AbE UJ <br />WELL PERMIT APPLICATION FORM 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 andtor install the work described. This application is made in compliance with <br />San Joaquin County Development Title, Chapter 9-11152 and the Standards of San Joaquin County public Health Services, Enviroosmnensoals earth Division, <br />3 ? 3 0 A,,- , /411iif � Cross Street C4`64« City S�'�K/V^ zip Parcel# <br />WELL Location jj jj J <br />�(uin�F �<v�.� Address �4^'t City Zip Phone# <br />PROPERTY Owner 14,1` <br />/'' n((� Address 15 ^/� 12� City 21p2�Ii�3-7 Lic# �(8S(6�Phone# �f7) )?(3 S oc� �/ <br />C-57 Contractor C9r' <br />u%� S -Add �< c '3,,,Cc4_L ,LidF Phone#,�(6�4Z9- L 3N6 <br />Consultant ( Sub Contractore�1 <br />GIS Coordinates: <br />Y , Township Range Section C) <br />WORK TO BE PERFORMED <br />OEW WELL/ BORING (CPT, GEOPROBE, HYDRQPUNCMDESTRUCTION (choose type below) 17— <br />, H ND -AUGER, OTHER") p p OVER -BORE � <br />�501L BORING# �S Q Z • 3 PRESSURE GROUT <br />p WELL # /I <br />'Other <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />MONITORING ,WHOLLOW STEM DIA. OF BOREHOLE S' MULTIPLE CASINGS? o YES If NO WELL CASING DIA: - <br />p EXTRACTION p AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: a STEEL 0 PVC 0 OTHER; , <br />p VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: D AUGERS pHOSE <br />p AIR SPARGE a PUSH POINT GROUT SEAL PUMPED: Q Yes a No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />-rSOIL BORING p HAND AUGER APPROX, BORING DEPTH Q BOLTED TRAFFIC BOX or I] STOVE PIPE <br />p OTHER;_ ,Q OTHFR CONDUCTOR CASING PROPOSED? ( If YES, list specifications here): <br />COMMENTS: <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 taws. 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 shah not employ persons subject to WORKERS' COMPENSATION Laws of Callfomia." Contractor's hiring or sub- <br />: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to <br />contracting signature certifies the following <br />WORKERS' COMPENSATION Laws of Ca/ifomis. _ _ <br />;N4!0,411II 'II�RS;1N AD. 1(ANC ERF.,CMks,Al1 IE�tlCALTllrlVIfNOR,a& <br />1RED#"IAiSP.- <br />+ <br />Signed x Title/Company <br />Lo Lx IC • G N <br />/i <br />Print Name /' Dal "LAv9tA1tV fllUl11ti6f�31te ��i <br />DEPARTMENT USE ONLY u c 3/1-25 a� <br />Application Accepted By Date Issued <br />Grout Inspection By Date }o d Z/ 0-Pinal Inspection By Dale <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS; <br />"1/18/2000 <br />d C!/ e <br />3 8� S 6 Ld►° <br />