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COMMENTS: <br />TYPE OF WELL <br />Iff/IONITORING <br />g EXTRACTION <br />0 VAPOR <br />AIR SPARGE <br />SOIL BORING <br />OTHER: <br />CONSTRUCTION TYPE <br />trgOLLOW STEM <br />O AIR HAMMERJDRIVEN <br />O MUD ROTARY <br />Q PUSH POINT <br />HAND AUGER <br />9-22-1999 [1:00PM HKLJN1 <br /> <br /> <br />WELL PERMIT APPLICATION FORM <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 />UNIT IV <br /> <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. Assassof <br />WELL Location CO 25 - t %AS ClorICI rA‘ c /6\1142. • Cross Street ii)40C-11-r AVAi • City CAVC Zip ParceI# al, - 101-0 0 <br />CA o-AtS r4c <br />PROPERTY OwnertV‘I\er C11431\ ..‘ kusilr1 Addresst031w. Nord.. IA al . SbAt s•lepitySi•OCkl'Oh Zip°621(1 Phone# s 3 Pke i S ,„n <br />C-57 Contractorerei Dr.% tk.% h5 Address CAS0 W t kli • Cityt\C441'11\a ZilliAt‘SS .1 Lidis1516 SP hone1et 15)31 3' S goo <br />Consultapt i Sub Contractorai"‘Ttr .C• C-441\VPANe-hA-Cia Address')." 0 ti/e\--K% yNS St - <br />, Township <br />WORK TO BE PERFORMED <br />1014W WELL / BORING ( CPT, GEOPROBE. HYOROPUNCH. HAND-AUGER. OTHER") <br />S IL BORING <br />ELL # tkVJ • + MAL/ --11 <br />U DESTRUCTION (choose type oelow) <br />0 OVER-BORE <br />Q PRESSURE GROUT <br />'Other: <br /> <br />CONSTRUCTION SPECIFICATIONS I (1) <br />DA. OF BOREHOLE, MULTIPLE CASINGS' a YES a14a WELL CASING DIA: 4 <br />CASING THICKNESS SC 't 0 TYPE OF CASING: 13 STEEL a-PVC a OTHER: <br />DEPTH OF GROUT SEAL e‘-' & 6 TREMIE TYPE TO BE USED: 114(UGERS QHOSE <br />GROUT SEAL PUMPED: efes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />APPROX. BORING DEPTH Ao eq, o OLTED TRAFFIC BOX or 3 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? t%)() ( 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 />arid Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: <br />"I 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." <br />Contractors hinng or sub- <br />contracting signature certifies the following: l certify <br />that in the performance of the work for which this permit is issued. I shell mploy persons subject to <br />WORKMAN'S COMPENSATION Laws of California.' <br />T AP LI MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />Tit' 0000ydaCte <br />SEE SITE MAP IN UNIT IV WORK PLAN DATED <br />DEPARTMENT USE ONLY <br />Application Accepted By ( Ann rrA,--. Date Issued /0 /Li /C' Area <br />Date 11( ) Final Inspection BY ("64A46.(4,......_ DatellT{ <br />Grout Inspection By tA <br />Destruction Inspection By Date <br />CitySON11"0.. Lic# Phone#(70-ncl 3S 't$G 0 <br />Range Section <br />GiS Coordinates: X <br />(1-1 <br />Signed x <br />COMMENTS / CONDITIONS: <br />FAC# <br />ACCOUNTING ONLY: <br />PE CODES FEE INFO <br />JOE.. <br />AID* <br />AMOUNT REMITTED CHECK/CASH <br />13-C3 <br />DATE PE21_,AIILSSRvicF RFOUELNt1MER <br />!cloy <br />INVOICE 1, <br />RECEIVED BY <br />oo,A5i-12,0 <br />Sr/