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WELL PERMIT APPLICATION FORM UNIT IV <br /> <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 />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 />Ave.) Assessor's <br />WELL Location ‘•(-tc_. Cross Street 6-9 4-1,,\-- Si-. City 54-,,,kiz-r. Zip ci S-202- Parcel# <br />PROPERTY Owner lh ak Address City SI-tx..11-c,rs Zip q5z02.. Phonett(20)i/7 19 <br />C-57 Contractor C-r-45cc-cle 'an I lo,-) Address '363 2. 0/0.¢c_(sae._ CityZ,Loc,.k.e.ZipiS 74 2 Lic# I 7 90 Phone#6 /4) 63&H 19 <br />WORK TO BE PERFORMED <br />OEW WELL! BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER") <br />0 SOIL BORING # <br />13cWELL # 1 -7 4. mu.,-1 9, <br />0 DESTRUCTION (choose type below) <br />I] OVER-BORE <br />B PRESSURE GROUT <br /> <br />*Other: <br />COMMENTS: <br /> <br />TYPE OF WELL INSTALLATION TYPE <br />(MONITORING HOLLOW STEM <br />0 EXTRACTION fl AIR HAMMER/DRIVEN <br />fl VAPOR I] MUD ROTARY <br />0 AIR SPARGE fl PUSH POINT <br />0 SOIL BORING Q HAND AUGER <br />I] OTHER OTHER <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE 5 " MULTIPLE CASINGS? I] YES Iff,NO WELL CASING DIA: 2 " <br />CASING THICKNESS . I/0 TYPE OF CASING: I] STEEL VPvc Q OTHER: <br />DEPTH OF GROUT SEAL 'IC ' 78 TREMIE TYPE TO BE USED: I] AUGERS t8f1OSE <br />GROUT SEAL PUMPED: *Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />APPROX. BORING DEPTH 60 ' el qo' gBOLTED TRAFFIC BOX or I] STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( 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 />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: "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 />T1 APPLICMIT MUST CALL 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />Title Pro,)C-0" I- 5 4- Date SIS /6)1 <br />SEE SITE MAP IN UNIT IV WORK PLAN DATED: 31 Ca 1 0 C <br />DEPARTMENT USE ONLY <br />Application Accepted Byptt* Date Issued n / <br />Final Inspection By <br />COMMENTS / CONDITIONS: <br />Al D# • <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # <br />1-1-klAT <br />REC'D BY DATE PERMI - • II - - INVOICE <br />3501 ekkuo el ooq ;s ,L.4-4-0, <br />_ _ __ _ ..._ <br />3- ,/ SR# cx)32690R 0 7 ....-7.-,........... ,r,re^,1 t,T A 13 A q--rrynT <br />C-57 LICENSED CONTRACTOR MUST SIGN <br />UNIT IV - 6/23/99 /sign bkpg/MI <br />601-f-fe, - <br />Consultant / Sub Contractor Address3106o1bCc...? Or) I 70 Citya G4t,,sLic# 55 11 <br />GIS Coordinates: X Y , Township Range Section <br />Phone#61‘) 6 3 (-- )30t, <br />Signed x <br />Grout Inspection By <br />Destruction Inspection By <br />Date <br />Date <br />I Area <br />Date