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DEPARTMENT USE ONLY <br />Date Issued 44. OG <br /> Final Inspection By <br />Ch,77:171717L <br />Date <br />Date <br />Area <br /> 06EP5Z <br />Date <br />WELL PERMIT APPLICATION FORM <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. 00 -Si ict_ r697-1 wok, AkA.• TH8/InTor) R04/) Assessor's WELL Location Fl AG Ci T CH 0 iR n Cross Street (4474 al MI.'? City D.11._ 'Zip 9 52 Y-2, Parcel# CSS -326 -23 <br />&him <br />ORIGINAL <br />UNIT IV <br />PROPERTY Owner R Il4 O 6 cl K I /X) Address Ci4,i4 AL_ City 1-4 (3U Zips 5 2 1/2_ Phone(2.139 310 3•C_I <br />C-57 Contractor WC-..51- /--/A MV) 1 Address,' 17'-1 2.••Derc, i I) City cr4p,,%„p Zip 9 57 Vt2 Lick 559 977Phone# (9 /b)438 7,2 <br />tA, /15Rari9A., (do <br />Consultant / Sub Contractor iq Address 10 0S Lv City STpc("Ton Lic# 8(_)22 7Phonek2ca) Y 7/0 <br />GIS Coordinates: X , Township 3 iv Range 5 L._ Section 1 <br />WORK TO BE PERFORMED <br />?!fiEW WELL / BORING GEOPROBE, HYDROPUN-1, HA * A GER, OTHER') <br />OIL BORING c r- sr-• <br />*Other: <br />0 ELL # p.13 t iltaeloo <br />COMMENTS: <br />CONSTRUCTION SPECIFICATIONS <br />O NOTHER: 0 OTHER <br />0 AIR SPARGE „....ikPUSH POINT <br />0 VAPOR 0 MUD ROTARY <br />0 EXTRACTION 9 AIR HAMMER/DRIVEN <br />0 MONITORING a HOLLOW STEM <br />-OIL BORING 0 HAND AUGER <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br />APPROX. BORING DEPTH I $(3 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />GROUT SEAL PUMPED: 'es 9 No (NOTE: MAXIMUM FREE-FALL DEPTH !J. 30') <br />DEPTH OF GROUT SEAL Tr="4 ?'4 L kP/r/TREMIE TYPE TO BE USED: 0 AUGERS AlOSE <br />CASING THICKNESS A TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />DIA. OF BOREHOLE Z-,').) MULTIPLE CASINGS? DYES 0 NO WELL CASING DIA://1/14 <br />COMMENTS: P-A-SZO Qfl (PT Fi55. , tek)c‘ii-1.6(-)0, ) c/vSier/D t,v•k1/5 lisi;» bc 14.51.4 L L.k to <br />(-44 A t•- i/i ik ki2 Ocr-i te _ AT --1-1-h 5 Po Ac ,z., i <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: 'T 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-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 />HE APPLICANT MUST CALL 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />, Signed x PYY) (f,Sij\----- Title A 0 'Q.Ct CeP/0 5 r ti Date 0 3-zz-C , <br />SEE SITE MAP IN UNIT IV WORK PLAN DATED: <br />0 DESTRUCTION (choose type below) <br />0 OVER-BORE <br />0 PRESSURE GROUT <br />TYPE OF WELL INSTALLATION TYPE <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS / CONDITIONS: <br />v <br />ACCOUNTING ONLY: AID# <br />FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE INVOICE - - ejniNal_ -•-,-,rel.Ai:i .... T # <br />350 / MIti 67g) 4 i -5 / Y a i 3* 22, SR# DD1-35 - LICENSE &WORKERS' NSATION-DEC RATION <br />UNIT IV - 6/23/99 /sign bkpg/MI