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ST-I/ 46/ oc, Area 0 7 SI, <br /> <br />Date <br />WELL IPERMIT APPLICATION FOlitl 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 Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />S roc-K.7-0 n 1 JES LONA Assessor's <br />WELL Location S23o A), WES; LANA> Cross Street t, 4/Pa ihtE.City 5 TOC—KTO CIZip 95to 5 Parcel# <br />PROPERTY Owner tifify Dt Eick, Address f. 0. Box k .7 City 5Tcc.7cr zip952 0 i Phone# Zret • igiS ya/ <br />C-57 Contractor tAll-C-ht.1( lif15 Address 5543 0 4v Ti! WOr AL/C"r CityStga.10004ip 955'21/4 Lic# 773/7Phone#9/ It V b b <br />Consultant/ Sub Contractor A ,c. E. Address YO 0 5 N. wilhort t4fraity 5Toc.t(1or‘Lic# 6lkiL2.7 Phone# Zu4I ^ Y 107_fc, 0 6 <br /> Township eR N.) Range (I) Section <br />;1KNEW WELL / BORING ( CPT, GEOPROBE, HYDRQPUNCH, HAND-AUGER, OT#1.43°1-111431-SNI3111\11V\IN86NN 38I [11 DESTRUCTION (choose type below) <br /># MV.1 -1 M 1A)-2 IAJ-3 000Z LI AVIN 9 OVER-BORE <br />0 PRESSURE GROUT <br />ASOIL BORING # P•"7 <br />uwer. <br />COMMENTS: <br />GIS Coordinates: X <br />WORK TO BE PERFORMED <br />TYPE OF WELL INSTALLATION TYPE <br />XMONITORING N/CHOLLOW STEM <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN <br />VAPOR DMUDROTARY <br />0 AIR SPARGE 0 PUSH POINT <br />XSOIL BORING 0 HAND AUGER <br />0 OTHER: 0 OTHER <br />P 145k '4 <br />CONSTRUCTION SPECIFICATIONS t, <br />DIA. OF BOREHOLE IA " MULTIPLE CASINGS? 0 YES 0 NO WELL CASING DIA: 4- <br />CASING THICKNESSS04 (Nit "to TYPE OF CASING: El STEEL /K5VC 0 OTHER: <br />DEPTH OF GROUT SEAL to 11, TREMIE TYPE TO BE USED: ,,/(UGERS <br />GROUT SEAL PUMPED: I'es fJ No (NOTE: MAXIMUM FREE-FALL DEPT <br />APPROX. BORING DEPTH (DS Fk OStrIXBOLTED TRAFFIC BOX or 9 STOVE <br />CONDUCTOR CASING PROPOSED? Lo a ( if YES, list specifications here): <br />OHOSE <br />H IS 30') <br />PIPE <br />COMMENTS: 5E2. pprovED kkiprK PIA r•I DirrrED 0/ rk6Av4.4 -/ zo.e7 <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: "I 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 />CALL THE UNIT IV INSPECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />Signed x Title/Company PROSeCT. Qd°,/57 /40 v6 picLO <br />Print Name Date <br />SEE SITE MAP IN UNIT IV WORK PLAN DATED: '6 1 F-.6 zoac. <br />DEPARTMENT USE ONLY <br />Date Issued <br />Final Inspection By <br />Application Accepted By 6:-- el t--e...-o-e <br />Grout Inspection By ("4'.z.--i-o-e-- C;:-');, A, 4.,")--,3 Date <br />0 Destruction Inspection By 6eL.z,-V ' C-2,) Date ( 4, - (, - <br />COMMENTS / CONDITIONS: -5LA--(--eye 1.;)1' <br /> <br />ocie ,,, i'.. ax“.....11-ier.--LeA.' --i- iii,-.1.:E. .... <br />ACCOUNTING ONLY: AID# FAC# <br />, <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE P QUEST # INVOICE <br />>7)1 8" 1 ' '3 75-5- (-1-‘c Sli'Vd SR# CO d)-87-3 <br />1/18/2000