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TYPE OF WELL <br />0 MONITORING <br />0 EXTRACTION <br />VAPOR <br />0 AIR SPARGE <br />[I SOIL BORING <br />I OTHER: <br />CONSTRUCTION TYPE <br />0 HOLLOW STEM <br />0 AIR HAMMER/DRIVEN <br />1:1 MUD ROTARY <br />I PUSH POINT <br />0 HAND AUGER <br />PRoBE <br />DEPARTMENT USE ONLY <br />Date Issued 3 /2- (17 Area 350/ <br />Final Inspection By Date <br />Y\ <br /> / <br /> <br />N'(:`><-,2 1-0 <br />Date <br />Da e <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) 468-3450 <br /> <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> <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 />Assessor's <br />WELL Location 1001 • Y0 CEMIT cross street RAY Lo W AVECity MA 14E cA Zip 9533 parcei# 2.23 - 290 - 0_3 0 0 1) <br />PROPERTY Owner tlitsitiiA Ft r (AL (t40 1 Address PC 0 tZ 5 city Vi•c I Ali zip 9 5 ‘t8Zphone# 4-‘z -8t <br />VALLK-T eteoarr (2o) <br />C-57 Contractor Ft5Gt4 E-NV, Address 399 sttE R Ac e City seitiNes zip9SISZ Lic#9v3vg Phone# -3 .4. +0 <br />ANCK0 _Etc. „(916) <br />Consultant / Sub Contractor RAKiAG-E V. Address P0 eer9 City teithA tErA Lic# 5956 Phone# 351 - 32SO <br />GIS Coordinates: X , Y Township Range Section <br />WORK TO BE PERFORMED <br />I NEW WELL / BORING ( CPT.,OFOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />I SOIL BORING # IN% 811 <br />0 WELL # <br />*Other: <br />0 DESTRUCTION (choose type below) <br />o OVER-BORE <br />0 PRESSURE GROUT c), <br />COMMENTS: 11 OU 0PRGI'sE. 13011 iniCrS <br />CONSTRUCTION SPECIFICATIONS <br />-q) DIA. OF BOREHOLE 1-04 MULTIPLE CASINGS? fl YES I NO WELL CASING DIA: IAA <br />CASING THICKNESS NA TYPE OF CASING: fl STEEL 0 PVC 0 OTHER: l4A <br />DEPTH OF GROUT SEAL lg E ET TREMIE TYPE TO BE USED: 1:1 AUGERS IHOSE <br />GROUT SEAL PUMPED: J Yes I No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') (A <br />APPROX. BORING DEPTH 2.5 -E1- <br />CONDUCTOR CASING PROPOSED? I4 0 ( if YES, list specifications here): <br />COMMENTS: (,0 P t' OF woRis olrhiLeo tt4 RAN4 ,01- g14411ONMENthCc WORK PLAM, <br />DATED MAY l() 0 99 <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, 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 employ persons subject to <br />WORKMAN'S COMPENSATION Laws of California." <br />THE APPLICANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />Signed x Title C-ASO .A/€ Date <br />SEE SITE MAP IN UN T IV, WORK PLAN. DATED r4Asf Z, (99 <br />0 BOLTED TRAFFIC BOX or fl STOVE PIPE <br />/ <br />Grout Inspection By At 00 i <br />Application Accepted By <br />Destruction Inspection , ar r <br />COMMENTS / CONDITIONS: ›...471,- 0 ( ( <br />I , <br />ACCOUNTING ONLY: AID# <br />FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECKMASH REC VED BYI DATE PE SERVICE REQ k. .BER INVOICE <br />-3501 k 9,00 4 15-4-5 ,,,ei siam s7.00z0 3 I R , <br />UNIT IV - 6/1/99 /sign bkpg/MI