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<br />WELL PERMIT APPLICATION FORM UNIT IV <br /> <br />ORIGINAL <br />Range Section <br />WORK TO BE PERFORMED <br />(\SINEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH. HAND-AUGER, OTHER') <br />U SOIL BORJ,NG # <br />a WELL* >ee- wev-P-111444 <br />'Other <br />COMMENTS: <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 <br />Haw/ Title, Chapter 9-1115.3 and the Standards of San Joaquin County Pubiic Health Services, Environmental Health Division. <br />* 70 9- s-0 Assessor's <br />WELL Location Z701 N. arkebt taty Cross Street 5:14,44;tleir; City 9144=Y--gfroK Zip9S-2/„,._ Parcel# 117 - 060 • <br />PROPERTY Owner AmettoRe_./..EAre Address 2.721 Al.CtisTietelle*-#7eCt ity Pikr, AZ Zip8cevf Phone# <br />C-57 Contractor 64,7 ,.6..11;1.. Aodress 4/5"/D ff231.0e.- <br />Coi:sultant / Sub Contractor Blete5 Ei1/;tofialterfal Address ?O LE.E4,I1 64 s it 7/1 CIty Mr, A7- Lit <br />GIS Coordinates. X Township <br />Ei DESTRUCTION (choose type below) <br />a OVER-BORE <br />a PRESSURE GROUT <br />Cityileterbie-1. Zi pcPICS-3 Lice8S165- Phone#42S - 313 • 52300 <br />Phone#602 • -728-o-167 c:77 <br />TYPE OF WELL <br />'MONITORING <br />O EXTRACTION <br />O VAPOR <br />fl AIR SPARGE <br />O SOIL BORING <br />a OTHER: <br />INSTALLATION TYPE <br />71 HOLLOW STEM <br />fl AIR HAMMER/DRIVEN <br />MUD ROTARY <br />PUSH POINT <br />13 HAND AUGER <br />fl OTHER <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE 10 04” MULTIPLE CASINGS? /1 YES NO WELL CASING DIA: <br />CASING THICKNESS Se-IL-40 TYPE OF CASING: U STEEL PVC ['OTHER <br />DEPTH OF GROUT SEALZS-- YS- TREMIE TYPE TO BE USED: )(AUGERS OHOSE <br />GROUT SEAL PUMPED: jees fl No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />APPROX. BORING DEPTH gd )(BOLTED TRAFFIC BOX or a STOVE PIPE <br />CONDUCTOR CASING PROPOSED? 14) if YES, list specifications here): <br /> :2> <br />COMMENTS: See_ lAibeK-- PIA"- 4.1- 061/1-0. a44.41 Table. 3 <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 agents signature certifies the following: "/ 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: "/ certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to <br />WORKERS' COMPENSATION Laws of California.' <br />Signed x <br />COMMENTS / CONDITIONS: <br />SEE SITE MAP IN UNIT IV WORK PLAN DATED: XI, -7(.6€4:0e/e) -/54 9) <br />Title <br />r . .. ., . <br />487 144?-)1 0 — <br />Date Date Final Inspection By Date <br />Date <br />o6PCI DEPARTMENT USE ONLY <br />Date Issued Area <br />6 r2 , <br />c..,ereartAter„). ' Date <br />Appiication Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />ACCOUNTING ONLY: <br />PE CODES I FEE INFO <br />AID# <br />AMOUNT REMITTED CHECK # <br />FAC# <br />REC'D BY I DATE <br />...fx5raggetONAN.._ <br />. . <br />UNIT - 6723/99 /s'ign-bk-Pg/MI- <br />WOdd HdLE:17 666L-IE-2