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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) 468-3449 <br /> <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 ap'plication is made in compliance with San <br />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 />Cross Street ftV/PkiCe710 City 51-0C---t1".1 Zip 75-40-5 Parcel# <br />PROPERTY Owner W1 00 011-112-4-X-k- L.1•-)t Address M015 liJaCTCYA-) lf?-1:, City Srr--40 Zip i-S-20-5 hone(,041 ) <br />C-57 Contractor e. l4-- Wai.... Address WV/ E. C.IvAlitAtiy City 91--K) ZipqgiarLic#37/31.400Phone# (412-'74,14',y, <br />Consultant/Sub Contractor A 6 C.- Address 400c M. IJAL‘Chti WV City 5T-t'3 L c# Phone# <br />(----,,, <br />GIS Coordinates: X Y , Township Range Section <br />WOR Ci <br />a NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') <br />SOIL BORING # <br />0 WELL # ) <br />*Other: 1.2i2kr55., ift•tr" CivIkryr tAY <br />COMMENTS: <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE MULTIPLE CASINGS? U YES U NO WELL CASING DIA: <br />CASING THICKNESS TYPE OF CASING: a STEEL a PVC a OTHER: <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: U AUGERS [NOSE <br />GROUT SEAL PUMPED: U Yes U No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />APPROX. BORING DEPTH U BOLTED TRAFFIC BOX or ['STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here) <br />COMMENTS: t'Sr--,-Ts PC-73 IzT72-A-rLUX.) ) DIZZD <br />NOTE: OFFSITE 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: "1 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: "I 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 />THE AFF•L C0417 .MU$T.CALL.,48, WORNqlift$,IfiA0Aiii0t , <br />Signed x <br />SEE SITE MAP IN 4NIT IV WORK PLAN DATED: <br /> <br />WELL Location --3q00 aucl.0707ki <br />K TO BE PERFORMED <br />XDESTRUCTION (choose type below) <br />OVER-BORE <br />RESSURE GROUT <br />TYPE OF WELL <br />0 MONITORING <br />EXTRACTION <br />0 VAPOR <br />0 AIR SPARGE <br />fl SOIL BORING <br />.0-OTHER:Pif11-44-ft, <br />INSTALLATION TYPE <br />0 HOLLOW STEM <br />I] AIR HAMMER/DRIVEN <br />fl MUD ROTARY <br />fl PUSH POINT <br />U HAND AUGER <br />'7 OTHER <br /> F <br />Title <br />COMMENTS! CONDITIONS: <br />Date (C 77(r. i<;1) <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />(4:71"..-C <br />DEPARTMENT USE ONLY <br />Date Issued /C — 0 <br /> <br />Area r 7 <br />Date Date Final Inspection By <br />2- <br />7,17/4 4 7----A-1rx <br />,c,_ ( ,r :4A , - <br />AID# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # <br />I' frklAT <br />REC'D BY DATE <br />L. <br />PERMIT.I-S T # INVOICE <br />ZS-7) ck (c D -- Co 0 ----- iti• 3 00 c,..D /0//t (0 <br />-.- — ............ <br />sR# <br />mf •Nkr... VA% A ,AAAAllA T . i"..T A 113 A 'T'FfiCha" <br />C.57 LICENSED CONTRACTOR MUST <br />UNIT IV - 6/23/99 /sign bkpg/MI