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WELL PERMIT APPLICATION FORM UNIT IV <br />SAN JOAQUIN COUNTY PUBLIC HEALTH <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 NOV p y 2000 <br />(209) 468-3449 ENVIRONMENT HEALTH <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT/SERVICES <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 Division. <br />CA, Assessor's <br />WELL Location S. 0-klliTCK ST-. Cross streetAMbEaSCk/ CitySTogc(0,.1 Zip_Parceltl 147-IU0-3S <br />PROPERTY Owner[ ALIF61:`IA �8(h%iL ! L�Address t 5'S -i) IU F'QFMM/,4* Cilys% ,)-7 ZipA Phone# G ' %9`7 <br />C-57 Contractor EAIVI90KCBL. Address 4005 Al, IA/lLSOtiLj6L4Y City S%a CXP..btL Zip.>Za� Li ? 7 Phone#yG%-/40(0 <br />Consultant / Sub Contractor A iA Address 514'x' L- City LickPhone# ✓lo % -/61* <br />GIS Coordinates: X , Y , Township Range <br />OEW WELL/ BORING ( CPT,EOPROB YDR UN H, HAND -AUGER, OTHER') 0 DESTRUCTION (choose type below) <br />;gtSO1L ING# pOVER-BORE <br />0 WELL # 0 PRESSURE GROUT <br />0 MONITORING 0 HOLLOW STEM <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN <br />0 VAPOR 0 MUD ROTARY <br />0 AIR SPARGE PUSH POINT <br />j( -SOIL BORING 0 HAND AUGER <br />0 OTHER: n OTHER <br />U VnJ 1 muu I lun Jrcblrl VN i iwmp <br />DIA. OF BOREHOLE I,'S" MULTIPLE CASINGS? 0 YES KNO WELL CASING DIA: AI,4 <br />CASING THICKNESS A(A TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER:_ <br />DEPTH OF GROUT SEAL 3f1r TREMIE TYPE TO BE USED: GAUGERS IIHOSE <br />GROUT SEAL PUMPED: 0 Yes I(,No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />APPROX. BORING DEPTH 36' n BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED?&L9— (if YES, list specifications here): <br />COMMENTS: I Shc L 80Q.t AI(f o keST EAI6Q0lQZLgA dl; a1d&t1, WATJf== JA PP¢.e1C 3a' <br />ts:'1g& Za RE $ACLFt Lt kb 712 5u2r(J 2¢rGcTHEAlT <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: "1 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 Ca/fior ia." Contractor's hiring or sub- <br />contracting signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to <br />WORKERS'COMPENSATION Laws of Califomia."L— <br />Signed x � �"`- TaleS7AfF CJCCALJ06-1 S % Date I % - 8 <br />SEE SITE MAP IN UNIT IV WORK PLAN DATED: RFC MEN <br />� <br />) DEPARTMENT USE ONLY 1 <br />Application Accepted By � rNvC-(n^/ Aa Dale Issued <br />Grout Inspection By Date Final Inspection By Date <br />Destruction Inspection By Date0; ;�Ntal`H SE`_ <br />. Mil <br />COMMENTS <br />ACCOUNTING ONLY: <br />AID# <br />FACE' <br />PE CODES FEE INFO <br />AMOUNT REMITTED CHECK # <br />REC'D BY DATE <br />PERMIT I SERVICE REQUEST # <br />INVOICE <br />SRSr 1 „ <br />