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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) 468-3449 <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 evelopmen Tile happ•ter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />as <br />--ro r rActc— Assessor's <br />WELL -Location 1 kA-er Cross tr CL.(1Cor'n\o. City S-VoCI- Zip 93-202_ P arcel# (3°I - ZgO-09- 7 <br />PROPERTY Owner <br />cot 14..5 M-4 2 <br /> <br />c_ one# `12C---ercich-3-786 "OfjC) Ceq Address 5 1 Z C <br />520 --- <br />C-57 Contractor b•-)0.et:, 01".k61vi Address POSQ`A -;36 City(R0\i1,51-c-- Zip 9(-157 Lic#7 / 071.19 Phone# 701- 3 -The --(3a -0 <br />Consultant / Sub Contractor 6€41-er - Rya, I rkcs Address 311746o1SG......NePr., 2`/9 CityPadtto 6.rtie4Lic# 220793 Phone# '116 - 631 - <br />GIS Coordinates: X Y Township Range Section <br />WORK TO BE PERFORMED <br />ANEW WELL I BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />CI SOIL BORING # <br />XWELL# U-111 u- (3 <br />*Other: <br />COMMENTS: <br />0 DESTRUCTION (choose type below) <br />0 OVER-BORE <br />fl PRESSURE GROUT <br />TYPE OF WELL INSTALLATION TYPE <br />AMONITORING XHOLLOW STEM <br />fl EXTRACTION 0 AIR HAMMER/DRIVEN <br />VAPOR flMUD ROTARY <br />0 AIR SPARGE PUSH POINT <br />9 SOIL BORING 0 HAND AUGER <br />0 OTHER: U OTHER <br />CONSTRUCTION SPECIFICATIONS <br />DIA, OF BOREHOLE e' el MULTIPLE CASINGS? 0 YES gNO WELL CASING DIA: 2" <br />CASING THICKNESS Sck 40 TYPE OF CASING: 9 STEEL KPVC 9 OTHER: <br />DEPTH OF GROUT SEAL Q. TREMIE TYPE TO BE USED: Ni(AUGERS OHOSE <br />GROUT SEAL PUMPED: AYes U No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') A--) <br />APPROX. BORING DEPTH 5G-c- (otio,-(J OLTED TRAFFIC BOX or 9 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here) <br />COMMENTS: (A-leA1 - TO = 3044- (6r,-). Sexl +a e.1 - 12 TO = to rboA-Se.r.4+o 1064) <br />UJc TD <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: "I 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 />NT MUST CALL 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> <br />(-"Da.,/ CS k4e-4-Z-05 -) Title 6 eOLOStc Date <br />SEE SITE MAP IN UNIT IV WORK PLAN DATED: (21 1ct <br />DEPARTMENT USE ONLY <br />Date Issued 3 -,11) —6 6 <br />Final Inspection By 711. <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PER - T # INVOICE <br />35() <br />C-57 LICENSED CONTRACTOR MUST SIGN LICENSE & <br />UNIT IV - 6/23/99 /sign bkpg/MI <br />Signed x <br />-2.1z270-5 <br />Application Accepted By s-li-Y\ <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS / CONDITIONS: LA II .4ANirt...Q1 b. AA1./c2e..4 23S / <br />Date <br />Date <br />Area <br />Date _S