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ORIGINAL <br />WELL PERMIT APPLICATION FORM UNIT IV <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD <br /> <br />Af <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <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 San <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Divi on. <br />WELL Location 3.1:72:, 6.44( Pa, Cross Street City 57/260•60ip 5-2,02,Parcel# <br />FAys.TTF— Assessor's/ 0,5*(4 <br /> <br />Address 436 AdLity trOCKOVip 4757-41phone# ifa — 4/53 PROPERTY Owner OLt <br />zot4 <br />(.A <br />C-57 Contractor Cp -r Address 2.345" Wi&LoAA,4 city_57064-.1 vipWeistic# 672"45Phone# <br />Consultant/Sub ContractorThMit LL, giaogOaftimfass ems ph pit ceHlty LOP( Lic#/f07Z—Phone#348- 47.5frr/ <br />GIS Coordinates: X , Y , Township Range Section <br />WORK TO BE PERFORMED: N(ff,1,1-ff. \/FrD) <br /> <br />NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />a SOIL BORING if <br />ir WELL # <br />*Other: <br />O DESTRUCTION (choose type below) <br />MAR gorTffr.E <br />P moour‘E GROUT <br />ENVIRONMENT HEALI H <br />1%.4 1,0 44 <br />COMMENTS: <br /> PERMIT/SERVICES <br />Print Name 5"r?...01 FEK.I ue, CIO Date <br />SITE FILE ADDRESS/WORK PLAN DATE: Sc S , CA L .Forz.kii (//17/6 <br />3 -30 -o Area Date Issued <br />Final Inspection By <br /> <br />TYPE OF WELL INSTALLATION TYPE <br /> <br />I"MONITORING a HOLLOW STEM <br /> <br />EXTRACTION a AIR HAMMER/DRIVEN <br />VAPOR a MUD ROTARY <br /> <br />AIR SPARGE PUSH POINT <br /> <br />fl SOIL BORING HAND AUGER <br />OTHER: U OTHER <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE gII MULTIPLE CASINGS? U YES [WO'. WELL CASING DIA: Z il <br />CASING THICKNESS TYPE OF CASING: a STEEL Err< a OTHER: <br />DEPTH OF GROUT SEAL I/4 TREMIE TYPE TO BE USED: U AUGERS a-IC*3E <br />GROUT SEAL PUMPED: lees U No (NOTE: M,AXIMUM FREE-FALL DEPTH IS 30') <br />APPROX. BORING DEPTH Jig . 4 5.,I I6 OLTED TRAFFIC BOX or 0 STOVE PIPE <br />)1 CONDUCTOR CASING PROPOSED? VO ( if YES, list specifications here): <br />COMMENTS: S 0413-9 <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 WORKERS' COMPENSATION Laws of California." Contractor's hiring or sub- <br />contracting signature certifies the following: "/ 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 />Signed x <br />TH PECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS <br />Title/Company ierCeAtaiLL F00-744-P_,Ceptrz • <br />IA. t <br />DEPARTMENT USE ONLY <br />Application Accepted By <br />Grout Inspection By <br /> Date <br />Destruction Inspection By Date <br />COMMENTS (CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE • - • -VI - • S • INVOICE <br />569 t tqaki 6't 36Pi att a4 .'d.;; . I ____A <br />C-57 exp. WC/waiver C-57 Letter of Authorization to sign perm y 5/17/00