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WELL PERMIT APPLICATION FORM <br />UNIT IV <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) nEco(ED 304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 NOV 291999 <br />SAN JuACIUIN CAAJNTY <br /> <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PUBLIC HEALTH SERVICES <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This apphinallorisiitetntiel-klioottvliraItterwith <br />San Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />WELL Location,402—gir.icte, 4Vg7006 Cross Street eXsPe, city `kl(16-411./1 Zip arce Pl# 0 <br />Assessor's <br />PROPERTY Owner On Pe a/ 5,,a....,...5 Address Ad Sv‘ lioi City 50C-14-4rt. Zip 9.00) Phone# <br />7 '9"' <br />,4„, ^y , '2 5 <br />1/4.. / c <br />C-57 Contractor Address C/o-05 } City -71-1( 5 Lic# (utPo z 7hone# <br />ly <br />GIS Coordinates: X <br /> <br /> Township Range Section <br /> <br />WORK TO BE PERFORMED <br />6EW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) a DESTRUCTION (choose type below) <br />0 SOIL BORING # v\r • 3 tr v., - '-i V ,,,, - c fl OVER-BORE <br />r'WELL# ‘io,-.4, kik,v- -1 0 PRESSURE GROUT >:.) <br />*Other: v.1- - vv - -1 ' <br />1 1 COMMENTS: ---.., <br />1 <br />"? <br />Consultant/Sub Contractor An i 4- DriliA5 Address 51i, 7 5 . I City Lri; Lic# 4:1; ‘41 7Phrie <br />TYPE OF WELL INSTALLATION TYPE <br />O MONITORING 1a-Ht5LLOW STEM <br />O EXTRACTION 0 AIR HAMMER/DRIVEN <br />VAPOR 0 MUD ROTARY <br />ErAIR SPARGE fl PUSH POINT <br />SOIL BORING 0 HAND AUGER <br />U OTHER: 0 OTHER <br />COMMENTS: <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE V-1 MULTIPLE CASINGS? I] YES fl NO WELL CASING DIA:.2 <br />CASING THICKNESS 56-11 140 TYPE OF CASING: 0 STEEL PVC a OTHER: <br />DEPTH OF GROUT SEAL JO 750 TREMIE TYPE TO BE USED: EVAUGERS ['HOSE <br />GROUT SEAL PUMPED: (rYes U No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30' <br />APPROX. BORING DEPTH 5:P / D-B-OLTED TRAFFIC BOX or J STOVE PIPE <br />CONDUCTOR CASING PROPOSED? MO ( if YES, list specifications here): <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: "/ 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, I shall employ persons subject to <br />WORKERS' COMPENSATION Laws of California." <br />THE APPL C UST CA L 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />Signed x Title ///49 Date //-:29"-- <br />SEE SITE MAP IN NIT IV WORK PLAN DATED: <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection B <br /> <br />1 1 / Zq/q? <br />Date /e//A7Xnal Inspection By Date <br />Date <br />ARTMENT USE ONLY <br />Date Issued Area <br />COMMENTS / CONDITIONS. <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC' P : Y DATE PE ST # INVOICE <br />3 3-0 I 2'7.00 (as k j,/ 0 _1 Wilt sfito 2 / S oa <br />C-57 LICENSED CONTRACTOR. MUST, SIGN LI <br />UNIT IV - 6/23/99 /sign bkpg/MI <br />"TpRISERS' ECI4RATION