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Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS / CONDITIONS: <br />ORIGINAL <br />WELL PERMIT APPLICATION FORM <br /> 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 cUpliance 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 />f-,( • .1. 71-6 L City (tey,"1-111--Zip q 5-2-e -I Parcel# <br /> <br />1)/- city e 5' 7Phone# <br />C-57 Contractor ‘k) 6? 4 Lic#12i ft'cflPhone# 6/716 / Orr) <br />City eL /14 't Li c# 3 4t 75— Phone# 7 72 -3 6 <br />W.DE5T <br />rlq <br />WELL Location <br />Consultant / Sub Contractor Address 13N, 8-1) <br />f-e. <br />,./t( Address IT <br />Cross Street <br />,g PROPERTY Owner 1-(6,. ji <br />Address <br />L <br />GIS Coordinates: X V Township Range Section <br />Z-- <br />WORK TO BE PERFORMED <br />0 NEW WELL BORING ( CPT. GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') ESTRUCTION (choose type below; <br />0 SOIL BORING # .1(OVER-BORE <br />0 WELL # a PRESSURE GROUT 7206 3 f' f <br />'Other: <br />COMMENTS: <br />TYPE OF WELL CONSTRUCTION TYPE <br />*MONITORING KOLLOW STEM <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN <br />4VAPOR 0 MUD ROTARY <br />-)LAIR SPARGE 0 PUSH POINT <br />0 SOIL BORING 0 HAND AUGER <br />0 OTHER: <br />fit <br />sze.) (2- <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE MULTIPLE CASINGS? a YES NO WELL CASING DIA: <br />CASING THICKNESS -C Lt TYPE OF CASING: 0 STEEL r'VC 0 OTHER: <br />DEPTH OF GROUT SEAL -Fe 5 TREMIE TYPE TO BE USED: 0 AUGERS OHOSE <br />GROUT SEAL PUMPED: 1:1 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />APPROX. BORING DEPTH aL ) ej 0 BOLTED TRAFFIC BOX or U STOVE PIPE <br />CONDUCTOR CASING PROPOSED' ( if YES, list specifications here): <br /> <br />/CO /6z-te <br /> <br />COMMENTS: C "kIIt 6 <br /> <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS! <br />nereby 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: "I certify that in the performance of the work <br />for which this permit is issued, 1 shall not employ persons subject to WORKMAN'S COMPENSATION Laws of California." Contractors hiring or sub- <br />oontracting signature certifies the following: '1 certify that in the performance or the work for winch this permit is issued. shall employ persons subject to <br />WORKMAN'S COMPENSATION Laws of California." <br />THE APPLICANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />Signed x Title 7'?'1A--7-'t- (( 16. Date /1 (I "13 <br />SEE SITE MAP IN UNIT IV WORK PLAN. DATED 1(13(6ro 4,1,0/646/ <br />Date Issued 491 0 O Area 6.stri-- <br />DEPARTMENT USE ONLY <br />Date /-47- 0 1 Final Inspection By <br />Date <br />FAC# <br />• . .. <br />PE CODES FEE INFO AMOUNT REMITTED CHECKWCASH RECEIVED BY DA INVOICE ' iIVAIii NUMBER <br />..../ <br />350 Z-. W 1 1 ;-F . /Z ;; 02-50/ „ <br />UNIT IV - 5/99 /MI