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WELL r' ERMIT APPLICATION R...A/1 UNIT IV <br /> <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 and/or install the work described. This application is made in compliance with <br />San Joaquin County Development Title, Chapter 9-11153 and the Standards of San Joaquin County Public Health Services, Environmental Health Division <br />fleiNELit/ 12-0A 13 Assessors <br />Cross Street d' 7";2:60- City A.r.notie-cdil <br />WELL Location 4 erc"ZAMI Zip Parcel# 4ti- 11-40 - a:14 <br />PROPERTY Owner 5-Ma Address azo City '5WL:ft-rarta Phone# v-c2- <br />C-57 Contractor/'c'#,71' AtAirii4.03 Address 9'331 /(11-6 14 40 a City faceiliZi Zip/ Lic# 6;155-1>Phonet4('c)Z..e/ oz-re <br />Consultant/Sub Contractor Ott - Address g. . F'Y' 41-9 City doecome-,. Lic# Phone# kfl•?-4(2---10 <br />GIS Coordinates: X <br /> ,Township 72,5. Range Afife Section mo <br />WORK TO BE PERFORMED <br />2€0EAN WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') <br />0 SOIL BORING # <br />VELL # <br />0 DESTRUCTION (choose type below) <br />a OVER-BORE <br />O PRESSURE GROUT <br />'Other: <br /> <br />COMMENTS: <br /> <br />TYPE OF WELL INSTALLATION TYPE <br />gl/.10NITORING yerIOLLOVV STEM <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN <br />0 VAPOR 0 MUD ROTARY <br />0 AIR SPARGE 0 PUSH POINT <br />0 SOIL BORING a HAND AUGER <br />G OTHER: _._....__-__0 OTHER <br />CONSTRUCTION SPECIFICATIONS ce <br />DIA. OF BOREHOLE-1;0ln "MULTIPLE CASINGS? 0 YES 1)60 WELL CASING DIA: <br />CASING THICKNESS 51,0 40 TYPE OF CASING: 0 STEEL lia5VC 0 OTHER: <br />DEPTH OF GROUT SEAL rio , c TREMIE TYPE TO BE USED: 0 AUGERS Ait8OSE <br />GROUT SEAL PUMPED: ,Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />APPROX. BORING DEPTH'S-9D.0 0 BOLTED TRAFFIC BOX or CI STOVE PIPE <br />CONDUCTOR <br />- <br />CONDUCTOR CASING PROPOSED'? /Jc. ( if YES, list specifications here). <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 agent's signature certifies the following: "/ <br />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 this permit is issued, I shall employ persons subject to <br />WORKERS' COMPENSATION Laws of California." CAL THE UNITIV INSPECTOR 43 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />/k) Title/Company PC/ 14;•s-•Virtea..." -rocif <br />1" / f)'c Date Z" "z' <br />SEE SITE MAP IN UNIT IY WORK PLAN DATED:. <br />DEPARTMENT USE ONLY <br />Date Issued <br />Date <br />COMMENTS / CONDITIONS: <br />(1414 <br /> -r <br />ACCOUNTING ONLY <br />Signed x <br />Print Name <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />r <br />MINTZ/ W4N <br />MEW CC I- C <br />110 <br />A DatedilMT a nal Inspection By <br />Date <br />(47V2 2 ?WO Area 3,10 <br />•