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WELL PERMIT APPLICATION FORM UNIT IV <br />g 2- <br />ORIGINAL <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVRONMENTAL 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 cornpiance with <br />San Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin Count/ Public Health Services, Environmental Health Division. <br />G4 - !kW #1 70f-5-C) Assessor's WELL Location2-701 P'• kti:/5 "1- 14-119, Cross Street 2_t_71m cit‘, Sfi:a4 ropt zip95-2is Parcel# <br />0 <br />PROPERTY OwnerAl+tete_p OsZa0 Address 2.721 N.ce..aii.a4 <br />,ti 7e, <br />jty r <br />Col:sultant / Sub Contractor.gheS emo'40.4mem GiAddress 2.02- gE4.-// A. 0176 City A 2--Lct Phonelt‘.6)2- 7 1t-670 7 <br />GIS Coordinates, X Y Township Range Section <br />Zip8S-00ii Phone# <br />C-67 Contractor P‘r-eC..1Sils-rt. 2,641)1'wty Aodress NCO s-oe 5f- city Rklugioa Zplqiez`fLic,# Phone#SCO*C7I -174,1 <br />TYPE OF WELL <br />9 MONITORING <br />LI EXTRACTION <br />a VAPOR <br />fl AIR SPARGE <br />XSOIL BORING <br />a OTHER: <br />iNSTALLAT;ON TYPE <br />r] HOLLOW STEM <br />fl AIR HAMMER/DRIVEN <br />I] MUD ROTARY <br />PUSH POINT <br />HAND AUGER <br />O OTHER <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE 2.'1 MULTIPLE CASINGS? a YES U NO WELL CASING DIA: 2. <br />CASING THICKNESS TYPE OF CASING: )STEEL fl PVC CI OTHER <br />DEPTH OF GROUT SEAL7bIa.1 TREMIE TYPE TO BE USED: U AUGERS arlOSE <br />GROUT SEAL PUMPED: X[Yes U No {NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />APPROX. BORING DEPTH I/O a BOLTED TRAFFIC BOX orfl STOVE PIPE <br />CONDUCTOR CASING PROPOSED? Aro ( if YES, list specifications here): <br />Ag :WM% <br />id 19 Signed x Title Date <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br /> <br />Area <br />Date Final Inspection By Date <br />Date <br />DEPARTMENT USE ONLY <br /> Date Issi.:ed -z9 <br />WORK TO BE PERFORMED <br />615NEW WELL BORING ( CPT, GEOPROBE, HYDROPUNCH. HAK-AUGER, OTHER*) <br />HMI. BORING # gee. 01.101-K. neot <br />U WELL <br />DESTRUCTION (choose type below) <br />a OVER-BORE <br />El PRESSURE GROUT <br />*Other: <br />COMMENTS: <br /> <br />COMMENTS: cdOek--- Pict"- 4." Pe ra.:/5 <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br />! nereby 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 iss:.Jed, 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, I shall employ persons subject to <br />WORKERS' COMPENSATION Laws of California.' <br />SEE SITE MAP IN UNIT IV WORK PLAN DATED: -N-y9 <br />COMMENTS / CONDITIONS <br />ACCOUNTING ONLY: <br />PE CODES FEE INFO <br />AID# <br />AMOUNT REMITTED REC'D BY TO—ATE CHECK # <br />00 <br />MIT / NVOICE <br />L 350/ 5e, 3c9 Ck.- 0 <br /> <br />C7.7..LICENSEW:CONTRAGTOKIVIVS7(Si(1, 4g4ittll$AUOX- tirsirr :v - 6/23/99 /sign bkpg/MI <br />1/10d3 WdLE'V 6661-LE-F, <br />'1.