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Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS / CONDITIONS: <br />YlAt" W " IN <br />,I7) <br />ni--B??ARTMENT USE ONLY <br />Date Issued <br />nal Inspection By Date A I Uffiffdl _ Date 6 <br />Date <br />AiT4MENIRMW*AISTREIM.717/11J <br />arA__24- yçqr / 6° 0 Area <br />WELL PERMIT APPLICATION R,RM 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) 463-3449 <br />("'s • I 3 <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'sr, <br />WELL Location ap.no Kit 14k1-)y 79 Cross Street "F:1\9")1(1..Y‘n City MO(.0-CICL. Zip TS-011 Parcel# 035 I pc) <br /> <br />PROPERTy Owner <br />sr c..."1-r'id1/4JA,N Address 23(pC k(--)T4/C\Vv‘ City itpckdekti, W.8_,,s1224bphcne# 4(9S—E7i )-- <br />Consultant / Sub Contractor(.../Y1MAY-4 Ze..rD 76FAI1.{SPress "7(4 rta1/4 tvxSt City C )01/1 Lic# RI-2N CM ne# EW' <br /> Township D.- ki <br />‘KHOLLOW STEM MtQc lir/DIA. OF BOREHOLE1714 I) MULTIPLE CASINGS? YES,. LIO WELL CASING DTAraf'i I/ <br />0 AIR HAMMER/DRIVEN CASING THICKNESS 5c14. 40 TYPE OF CASING: p(PVtatAROTHER: <br />XMUD ROTARY tALLISi ct DEPTH OF GROUT SEAL ...-1 P1/41 TREMIE TYR:: ro BE USED: Nt AUGERS HOSE <br />0 PUSH POINT GROUT SEAL PUMPED: XYes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />e,4_c& <br />0 HAND AUGER APPROX. BORING DEPTH 10 11-3•7 , „I 0 BOLTED TRAFFIC BOX or <br />0 OTHER: 0 OTHER CONDUCTOR CASING PROM?)%7EIg91 ( if YES, list specifications here): <br />Ptr- <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, anc 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: '1 certify that in the performance of the wcrk for which this permit is issued, I shall employ persons subjeg: to <br />WORKERS' COMPENSATION Laws of California.' <br />HE APP ICANT MUST CALL 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />Signed Signed x Title g(1-` D a t e teLoo <br />SEE SITE MAP IN UNIT IV WORK PLAN DATED: .ilAv\E__ 0 0 <br />ACCOUNTING ONLY: AllIlt FAD!! <br />P.E CODES FEE INFO AMOUNT REMITTED I CHECK tit REC'D BY DATE PERMIT! SERVICE REQUEST # INVOICE <br />9 ct .W I oto ( q-Z,N,W4 giAA0 s R# 42(14'?4_ <br />C-57 LICENSED CONTRACTOR hIUST SIGN LI NS <br />UNIT Iv - 6/23/99 /sign bkpg/MI <br />Address at() ctis. City C40C-Y-bil Zip c6")11-Phone# (Apt, (77 <br />C-57 Contractor <br />GIS Coordinates: X Rance 7E- Section (0.-) <br />WORK TO BE PERFORMED <br />0 NEW WELL! BORING ( CPT, GE-.0PROBE, HYDROPUNCH, HAND-AUGER, OTHER') 0 DESTRUCTION (choose type below) <br />0 SOIL BORING f4 0 OVER-BORE N.Q <br />ErWELL # ML) rAL.06,, mrcf7, 0 r:-....,,,,,. GROUT --, <br />'Other: <br />COMMENTS: ktk..)c, fr..wc.e, itkuz7 titA ECU( t4615•N kb 70' #41-14 % (kW.) P-OfeV\[ i ft, ^-1061 . mu.)9 1-t-4.1 Payit-1 -10 . . <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />XMONITORING <br />EXTRACTION <br />0 VAPOR <br />0 AIR SPARGF_ <br />0 SOIL BORING <br />COMMENTS: CO 3C.) 100 L.t.p3/kc— P16.11 <br />STOVE PIPE <br />uk. <br />cvaLS +W<-)k-'5-1A. ZOvve-S