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DEPARTMENT USE ONLY <br />Date Issued <br />Application Accepted By { <br />Grout Inspection By <br />Destruction Inspection By <br />Final Inspection By Date ' <br />DateDate <br />COMMENTS / CONDITIONS: <br />Area <br /> Date <br />UNIT IV - 6/23/99 /sign bkpg/MI <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) 468-3449 <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 />54e1...02.Ves 308 14. O.\ C. otiser Ave_ <br />Sk•ockA-o.n Zip i6202- <br /> Assessor's c ik.,1 <br />Parcel# Pro per-l-ct <br />WELL Location Stdewo.kk 6cib A,Q.. Cross Street Att-^eNtari 5.4. City <br />PROPERTY Owner CI Irti S-63c1(41:Pc. Address q26 N. el Oory.alo S. city Zip qC 202-Phone# 209 -q3 -7-- 8'1'6 1 <br />C-57 Contractor (Nocawo-nc) Drt \\Nr5 Address Po 3 S 6 CityRo .VIsk-ck Zip 9q57( Lic# 79 phone#-/0/-374-'150-D <br /> <br />t4erz.5 3140 604C. Dr <br />Consultant / Sub ContractorGe•Wor Rtio,e‘ 6\4.. Address 5, 14.e_ e) CityVioiArlo C-04.Lic# 72,t Phone# ‘i16 - 631- 13(76 <br />GIS Coordinates: X , Y , Township Range Section <br />WORK TO BE PERFORMED <br />*NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') <br />0 SOIL BORING # <br />OWELL # 111W - SP- 5-0,8A SP-6 OA 0 <br />O DESTRUCTION (choose type below) <br />OVER-BORE <br />0 PRESSURE GROUT <br />tiVIRONMENT HEW H <br />02 FEB - I PM I Li I <br />*Other: <br />COMMENTS: <br />TYPE OF WELL <br />ir'MONITORING <br />o EXTRACTION <br />0 VAPOR <br />gAil•R SPARGEOZoN6 <br />O SOIL BORING <br />0 OTHER: <br />INSTALLATION TYPE <br />HOLLOW STEM <br />0 AIR HAMMER/DRIVEN <br />O MUD ROTARY <br />0 PUSH POINT <br />0 HAND AUGER <br />0 OTHER <br />CONSTRUCTION SPECIFICATIONS u/3/ <br />DIA. OF BOREHOLE a " MULTIPLE CASINGS? 1:1 YES 111,4q0 WELL CASING DIA: 2 /Y <br />CASING THICKNESS Sat., Lio TYPE OF CASING: J STEEL Ifspvc OTHER: <br />DEPTH OF GROUT SEAL%) 60/ Icro,10 3 TREMIE TYPE TO BE USED: 0 AUGERS WOSE <br />GROUT SEAL PUMPED: pres U No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />APPROX. BORING DEPTH ABOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br />COMMENTS: OfiNie_ YVV,,AALsett-5 0-€..A1 4-0 = Izo' (19 ft.t.,1- -Ir.. 103 oz9re- \Is in <br />pcx),_)ps c4- Mm-ee. 1,..,a) to -Tp '40 1, 61;, Ile sec..1.5 4 3 1, 6 1, er tot.> re,s <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 />TH APB&JCANT MUST CALL 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />Title CevvoC Date <br />Signed x 9 s27( <br />SEE SITE MAP IN UNIT IV WORK PLAN DATED: <br />ACCOUNTING ONLY AID# FAC.# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT / SERVICE REQUEST # INVOICE <br />C-57 LICENSED CONTRACTOR MUST SIGN LICENSE &WORKERS' COMPE SN DECLARATION