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WELL PERMIT APPLICATION FORM 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) 468-3450 <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 />Assessor's <br />WELL Location C F-METIE RN LANE Cross Street HA RD i NCr City StocicToN Zip 9 520 Li` Parcel# U ZI- -700 -02. <br />SAN 7CAQVIN ,-.._ • • (7,0.9) <br />PROPERTY Owner CATI:10 L t C GEM E r E RI Address PC. Box it 31- city 1 oc o FoN zip 9C201 Phone# Li <br /> <br />Ci R G:-(..i• PR (LUNG- ‘i-MARTINEZ --f--57.-- (910 <br />uS C-57 Contractor TiN G , INC . Address 950 1-10Nr '. RD. City CA zip-AS53 Lia#6 5 6 4 OtPhone# 3 13 ~ 5 2 CC <br /> <br />, , <br />TOSEPH RAMAG-E i' 0, (3 ox e,-.. 9 R. (i. <br />GIS Coordinaes: .; 'I Tows!-,ip r,coly SeCt:Ca;i <br />WORK TO BE PERFORMED (-4 <br />0 WELL # <br />a OVER-BORE <br />D PRESSURE GROUT <br />I NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') 0 DESTRUCTION (choose type below) <br />I SOIL BORING # CPT -1 * <br />: 'Other: <br />COMMENTS: Ac I CN -5iTE CPI DeAKINC- <br />X TYPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING a HOLLOW STEM DIA. OF BOREHOLE I, C " MULTIPLE CASINGS? a YES I NO WELL CASING DIA: NA <br />a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS NI\ TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: NA <br />\' <br />0 VAPOR a MUD ROTARY DEPTH OF GROUT SEAL T Dm IOC i TREMIE TYPE TO BE USED: a AUGERS ()HOSE <br />fl AIR SPARGE g PUSH POINT(C p T) GROUT SEAL PUMPED: I Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />1 <br />I SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH 100- FT a BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />NK, <br />V' <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 WORKMAN'S COMPENSATION Laws of California." Contractor's hiring or sub- <br />contractina sianature certifies the followina: "/ certify that in the performance of the work for which this permit is issued, I shall employ persons subject to <br />WORKMAN'S COMPENSATION Laws of California." <br />TH A LIC UST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />7//4/00 <br />SEE SITE MAP IN UNIT IV WORK PLAN. DATED APRIL 2.4,100Q <br />DEPARTMENT USE ONLY <br /> Date Issued 7P--(e/N9 Area <br />( Final Inspection By Date <br />COMMENTS / CONDITIONS: rer 170 (0 0° <br />1 .... <br />ACCOUNTING ONLY: AID# <br />FAC# <br />PE CODES FEE INFO AMOUNT REMITTED pHECI6-/ASH RECEIVED BY DATE P _ ..1:. QUEST NUMBER INVOICE <br />, iSt,Yq Nk 7 sRite207-- kg'e) .5"-Of Y5 - <br />a OTHER: CONDUCTOR CASING PROPOSED? NO ( if YES, list specifications here): <br />UNIT IV - 6/1/99 /sign bkpg/MI <br />Consultant / Sub Contractor RA M AG- F-- NV i I‘ 0 N. Address R <br />(.9i0 <br />A 1\lcii c mv E TA City 95- (A3 Lic# 5?S6 Phone# 3S 4-- 32 50 <br />COMMENTS: <br />Signed x notke Title <br />Application Accepted B <br />Grout Inspection By <br />Destruction Inspection By <br />Date <br />Date