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WELL PERMIT APPLICATION PORM <br />4i(1111-1-'d- WAL/ Cross Street <br /> City ---1/11 Zip 9S 7 Parcel# A <br />ssessor's <br />.Tilt-T Address 52,. 1--s-Ar-- 436 City Zip9-*Phone# e 1 442 <br />C-5 7 ContractorOtt- Address <br />.0 <br />.<5 41'1Cleti/i -P-41: City g. 6 CAZip ?....5e2kic#6572t)%Phone#9(4.2 3are Z2?-2_ )1/48ij 15k)Ciiei <br />Sub ContractorPrtr1C Address 4c5-6'. 4 ,(A51A4-) City Phone Phoner 1/16.7 115-S(3 <br />GIS Coordinates: X Y , Township <br />WORK TO BE PERFORMED <br />El NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />0 SOIL BORING # AL° 6 <br />El WELL # <br />COMMENTS: <br />INSTALLATION TYPE <br />)341onow STEM <br />El AIR HAMMER/DRIVEN <br />CI MUD ROTARY <br />a PUSH POINT <br />fl HAND AUGER <br />El OTHER <br />Pee55 6.07x-tr- <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 Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />WELL Location -1- <br />PROPERTY Owner er <br />UNIT IV <br />Range Section <br />*Other: <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE F* MULTIPLE CASINGS? [I YES 0 WELL CASING DIA: <br />CASING THICKNESS TYPE OF CASING: 0 STEEL fiPVC [I OTHER: <br />DEPTH OF GROUT SEAL /S. F-C--T-TREMIE TYPE TO BE USED: [I AUGERS OHOSE <br />GROUT SEAL PUMPED: ,Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />CONDUCTOR CASING PROPOSED? Np cif YES, list specifications here): <br />APPROX. BORING DEPTH /5-- ir--------7—A-BOLTED TRAFFIC BOX or STOVE PIPE <br />.ArtiESTRUCTION (choose type below) <br />0 OVER-BORE <br />ZPRESSURE GROUT '\\ <br />TYPE OF WELL <br />,24-0NITORING <br />O EXTRACTION <br />0 VAPOR <br />El AIR SPARGE <br />0 SOIL BORING <br />0 OTHER: <br />COMMENTS: <br /> <br />vere-t, <br /> <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: '1 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 APPLICANT MUST CALL 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />Signed x Itateztati9-- Title C-7751)4-j'/-- Date <br />SEE SITE MAP IN UNIT IV WORK PLAN DATED: <br />I -2. 7 -(A) <br />COMMENTS / CONDITIONS: (42 <br />Date <br />Date <br />DEPARTMENT USE ONLY <br /> Date Issued 2. - 3 - o 0 Area 0 1 56 <br />Final Inspection By_0A1,(4.4. 0 cy , v‘ L._ Date c- t,I./rC 41!_.4" • :. •"1.... eV' 1,o . <br />it.t.12.- r.t./7.4.51 4-4° <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />ACCOUNTING ONLY: AID# <br />FAC# <br />. <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE ' iimiuliK!'"-•••--t* QUEST # INVOICE <br />---- 3 21 c.) -- <br />SR# Oø?-(Si - <br />C-57 LICENSED CONTRACTOR MUST SIGN LICENSE &WORKRSCOMPENSAflO1 DECLARATION <br />UNIT IV - 6/23/99 /sign bkpg/MI