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AID# FAC# ACCOUNTING ONLY: <br />RMIT / SE—R—VIL T # INVOICE <br />PE CODES FEE INFO AMOUNT REMITTED RE 'co BY CHECK # DATE <br />7?- 3c;0 I Z1 SR# 0023 N <br />1/18/2000 <br />WELL PERMIT APPLICATION FORM UNIT IV <br /> <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 an(Vor 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 />Assessor's <br />WELL Location /1-Zi75 Cross Street /-4/1 /20 City /....,;17.44`,-",:l Zip <br />PROPERTY Owner glisci toesiArd cirf.t-Io-7.t.-- Address 7/1/ figs r .53-- City 7--.1-TCA 4.-4741 ZipWIWI Phone # 618 -3r93 <br />C-57 Contractor.csee...../771.1afAiliAddress (M3 /-44-0-00/441-ogd-City 5rbt,r12)-4.1 Zip 9<filf; Lic#,41.Keil4/ Phone <br />at) . -1 Consultant/ Sub Contractor /A...Ail"( Z Address " eJC, /90X Se City C4/.4,4&_;,-- Lic# Phone#0.4)4440 <br />AV (4, <br />GIS Coordinates: X <br />Parcel# 414-40- tlY <br />, Township Range /e7b- Section <br />WORK TO BE PERFORMED <br />XNEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') <br />5r-SOIL BORING # <br />XWELL # <br />0 DESTRUCTION (choose type below)' <br />0 OVER-BORE <br />fl PRESSURE GROUI—C. <br />'Other: <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE <br />XMONITORING fiaiOLLOW STEM <br />0 EXTRACTION 0 AIR HAMMER/DRNEN <br />,VAPOR 0 MUD ROTARY <br />9 AIR SPARGE 0 PUSH POINT <br />OIL BORING 0 HAND AUGER <br />0 OTHER: POTHER <br />DIA. OF BOREHOLE S MULTIPLE CASINGS? 0 YES -,likNO WELL CASING DIA:Zi".LEY7 <br />CASING THICKNESS 5Cel 40 TYPE OF CASING: 0 STEEL keVC 0 OTHER: <br />DEPTH OF GROUT SEAL VA c-v v "Joy TREMIE TYPE TO BE USED: 0 AUGERS AiitiOSE <br />GROUT SEAL PUMPED: Xles ,No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') p <br />APPROX. BORING DEPTH _14 for° 1030LTED TRAFFIC BOX or 9 STOVE PIPE (- <br />CONDUCTOR CASING PROPOSED? //0 ( if YES, list specifications here): <br />CONSTRUCTION SPECIFICATIONS <br />COMMENTS: <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 a gent'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." <br />Contractor's hiring or sub- <br />contracting signature certifies the following: "I <br />certify that in the performance of the work for which tills permit is issued, I shall employ persons subject to <br />WORKERS' COMPENSATION Laws of California." • <br />U THE JNIT I INSPECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIR D INSPECTIONS. <br />Title/Company <br />Print Name <br />Sig ned x <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS / CONDITIONS: <br />)(-1/ /5/ 4r- Date /::- /C Cr6 <br /> <br />SEE SITE MAP IN UNIT IV WORK PLAN DATED: <br />-s-v2 2 V Date Issued 2oz,-0 DEPARTMENT USE ONLY <br />i$:1111.11MOrVateLirial eVinal Inspection By Date <br />gra