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Aurtir 2 I <br />_ ;#.,4;(.1 <br />ORIGINAL <br />WELL PERMIT APPLICATION FORM <br /> <br />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 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 />WELL Location 1U/170 0.4)(111 Cji- Cross Street(OLAI Ak., City Zip Zip Parcel# <br />Assessor's <br />PROPERTY Owner iCAC.C; NAZIL-E14•K) . Address l0 e.atize, e0xE.A).LLE.,. Zip ckicird Ph# TN -(59 C) <br />et. 0 70 7 C-57 Contractor WL-CrYvvi/V.0 1'it.,u\JC, Address P O, E230X 33(4, city • \)vp, ziAls- 7 I Lic# 7 to cin Phan& 37(4 -1•SOC), <br />„ Consultant/Sub Contractor:LI CDepoeit-DO-J Address I 43 N. mpey....4-6Lety Svo_. Lic# Phone# 9 c53OOr i, %t, I <br />GIS Coordinates: X Township <br />Sk i <br />Range Section <br />WORK TO BE PERFORMED <br />*NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />0 SOIL BORING # <br />-SWELL # (\t' <br />*Other: <br />COMMENTS: <br />0 DESTRUCTION (choose type below) <br />0 OVER-BORE <br />0 PRESSURE GROUT <br />TYPE OF WELL INSTALLATION TYPE <br />sikONITORING '0-{OLLOW STEM <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN <br />0 VAPOR D MUD ROTARY <br />0 AIR SPARGE 0 PUSH POINT <br />0 SOIL BORING 0 HAND AUGER <br />fl OTHER: 13 OTHER <br />CONSTRUCTION SPECIFICATIONS C.1. <br />DIA. OF BOREHOLE <br /> <br /> s?", it <br />MULTIPLE CASINGS? BYES Iri40 WELL CASING DIA r. <br />CASING THICKNESS scA---ic..) TYPE OF CASING: 0 STEEL "PVC 0 OTHER - <br />DEPTH OF GROUT SEAL Zi i TREMIE TYPE TO BE USED: 0 AUGERS s-10S <br />GROUT SEAL PUMPED: 0 Yes 124s4o (NOTE: MAXIMUM FREE-FALL DEPTH IS 30 <br />APPROX. BORING DEPTH -"<k--, ' 0430LTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ,r\L.) ( 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: "/ 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: "/ 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 />T 'APPLICANT:MUST;7:CALL 413:1/1/00KNO-IRS.(N'AtiVANCE:PORA(14.?Quo3.0.0.iNsPgcTioNs. <br />Signed x //da./C(4,? 6c0C4:9761/4 -r EA/6 e. Date (-P / 1 q 00 <br />U <br />SEE SITE MAP I N T IV WORK PLAN DATED: AilAy I Zoo <br />DEPARTMENT USE ONLY <br />Date Issued 6 00 <br />Final Inspection By - <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS / CONDITIONS: <br />Date <br />Date <br />— NOV 22; 2000 <br />Area <br />Date <br />— <br />ACCOUNTING ONLY: AID# <br />FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE - ' / SER - • EST # INVOICE <br />/ Aid gl /2 g?' A 6-27 -; bto3ii,D <br />C-57 LICENSED CONTRACTOR MUST StGN:LICENSEtz\VO C TTON