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AID* <br />INVOICE-1 DATE <br />ACCOUNTING ONLY: <br />FAC* <br />CHECKNICASH R C ED BY <br />CMk <br />PE CODES <br />e <br />FEE INFO AMOUNT REMITTED <br />oc) <br />9-22-1999 d:OOPM FROM <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 />Parcel* <br />PROPERTY Owner 1-LC— Address PS , 14,, 37 Cy Ii54.0phone# 70 <br />L3 -5 gera <br />C-57 Contractor &rea) 3c;( /1,25 Address 9:57.7) Ho -'e City/14c1r Zip lin-3 Lid* Y.S.51 65 Phonef --- <br />CoiCsi-D Itant / Sub Contractor La.; int).:roeip-e^11(idress Licit <br />Section <br />WORK TO BE PERFORMED <br />fitNEW WELL / ( GEOPROBE. HYDROPUNCH. HAND-AUGER, OTHER') <br />SOIL BORING 5I3 -1 56-y <br />WELL tt <br />C.)3 <br />a DESTRUCTION (choose type below) <br />OVER-BORE <br />G PRESSURE GROUT <br />2," MULTIPLE CASINGS? a YES Q NO WELL CASING DIA: <br />TYPE OF CASING: [:1 STEEL Q PVC fl OTHER: <br />TREMIE TYPE TO BE USED: G AUGERS ['HOSE <br />No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />fl <br />(I <br /> <br /> (1 <br />BOLTED TRAFFIC BOX or G STOVE PIPE <br />( if YES, list specifications here): <br />COMMENTS: 1-1-01e5 ( ( it) St-f 1-ft),-)e , e e&iy crt <br />CPI QrJ 1p .h e ,-c--, <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 Ondinances. 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 WORKMAN'S COMPENSATION Laws of California." Contractor's hinng or sub- <br />contracting signature certifies the following: I <br />certify that in the performance of the work for which this permit i$ issued. i shall employ persons subject to <br />WORKMAN'S COMPENSATION Laws of California <br />THE PLICANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />110441 Title ITC"! Trddr fiv,m,,,yrate a//sior , <br />SEE SITE MAP IN UNIT IV WORK PLAN DATED <br />iP1 <br /> <br /> Area ZA6t/ 0 // t DEPARTMENT USE ONLY <br />..1 4 <br />I, I) i Date <br />ate <br />Issued ,/ t-,, <br />26, 0/ Final Inspection By 2,_ci ,t,,,t) I Date <br />Destruction Inspection By <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 />Assessors San JOaCluin County Deveiopment Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />WELL Location I I E.51- Lit Cross Street /I ; rto Lit) City -5 fo<14 ridni. Zip I <br />Phone#707--'W --Z3 r, f <br />GIS Coordinates: X Y Township Range <br />Other: <br />COMMENTS: `1 <br />TYPE OF WELL <br />j MONITORING <br />j EXTRACTION <br />VAPOR <br />G AIR SPARGE <br />,SOIL BORING <br />j OTHER: <br /> <br />CONSTRUCTION TYPE <br />Q HOLLOW STEM <br />G AIR HAMMER/DRIVEN <br />MUD ROTARY <br />,f,..PU,SH POINT ce 1 ,c1. <br />HAND AUGER <br /> <br />CONSTRUCTIOdSPECIFICATIONS <br />D. OF BOREHOLE <br />CASING THICKNESS <br />DEPTH OF GROUT SEAL <br />GROUT SEAL PUMPED: U Yes <br />APPROX. BORING DEPTH <br />CONDUCTOR CASING PROPOSED? <br />Signed x <br />Application Accepted Accepted By <br />Grout Inspection By <br />COMMENTS / CONDITIONS: