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LVVV 11:�G <br />ZU'J4bbd4JJ <br />r lr I n r LUUK <br />• <br />WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION {PHS-EHD <br />-,UNIT IV <br />` 11A1 <br />304 E. Weber, Third Floor, Stockton, CA., 95202 &Nv/RO 6 .r <br />(209) 468-3449pERMI11N-/v 000 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ASF N�q <br />pplication is hereby made to San Joaquin County for a permit to construct and/or install the work described- This application is made in colt $fin <br />oaquin County Development Title, Chapter 9-1115..3�and.the Standards of San Joaquin County Public Health Services, Environmenttaalea <br />H olsDlvis� n <br />ifELL Location -2651 SOL. i r o <br />IlVa Cross Street £ IZ-t�t City sTOG14TON Zip °l52 -t)6 Parcel# 1(09-�2O"�� <br />'ROPERTY Owner �^4 Ez'`f ' ai t^S Cc+^ti Address, 00 Mzr �2rid r��-e • City -�-. L - is • zip (03 10 5Phone# 3[4 259 -70 3 <br />85I- 5PInone#1725 313 -5156c> <br />-57 Contractor -6R PP-1LLZ. 6Address 15 O �w 6- RD cityQ,t2T1a/ ip 94553 Liott,` <br />at"'ua� Lac# Phoned fs a l - 55 2 <br />;onsultant I Sub Contractor r'l fit--W-WLVZC' Address 2/6 W swo A4,UK RAC <br />ity_ tx � <br />W 1 I Irl Range- E Section 2 <br />Y�► 2 <br />IS Coordinates: X 121 "1,53 —. Y n 7 55.G'�i l Township g <br />HORK TO BE PERFORMED: <br />,*NEW WELL 1 BORING ( CPT. GEOPROBE, HYDROPUNCH. HAND -AUGER. OTHER-) <br />0 SOIL BORING # <br />IWELL # V <br />,Other: <br />COMMENTS: <br />TYPE OF WELL <br />INSTALLATION TYPE <br />0 MONITORING <br />a HOLLOW STEM <br />0 EXTRACTION <br />0 AIR HAMMERIDRiVEN <br />4 VAPOR <br />0 MUD ROTARY <br />0 AIR SPARGE <br />0 PUSH POINT <br />0 SOIL BORING <br />0 HAND AUGER <br />Q OTHER: <br />0 OTHER <br />0 DESTRUCTION (choose type below) <br />0 OVER -BORE <br />jjPRESSURE GROUT <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE NIULTIPLE CASINGS? DYES ONO WELL CASING DIA: <br />CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC [I 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 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? (if YES, list specifications here): <br />COMMENTS: <br />ACCESS OR ENCROACHMENT PERMITS <br />NOTE: OFFSITE BORINGS REQUIRE <br />I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquln County Ordinances, State Laws, and "! certify that in the performance of the work <br />and Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: <br />!s issued, !shall not employ persons subject to WORKERS' COMPFNSA71ON Laws of California." Contractors hiring or sub - <br />for which this permit dies the fallowing "I certify that in the pe1'formanca of the work for which this permit is issued, I shall employ persons subject to <br />contracting signature Is <br />WORKERS, COMPENSATION ws of Cali rnia," <br />*CAL TH P TOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED, INSPECTIONS <br />Signed x <br />Title/Company �� �G�!�EG%�/✓/>jG�-p��ZL�SI�I <br />Print Name <br />l'ueT sig 70' Da <br />SITE FILE ADDRESSIWORK PLAN DATd,S2z� ��� X9'093 <br />Application Accepted By <br />,b• rRz ,/Ny 70,10 <br />Issued, �+ U Area <br />Flnal Inspection By <br />Grout inspection By <br />Destruction Inspection By Date <br />COMMENTS /CONDITIONS: <br />ACCOUNTING ONLY: AID# <br />PE CODES FEE INFO AMOUNT REMfTTED CHECK # RE C'D SY DATE <br />ERVIc 57 # INVOICE <br />it Encroachmen <br />-�i7 exo WC/waiver C-57 Letter of Authorization to sign perm <br />t oc 5/17/00 <br />