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lowl <br /> } i <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUI <br /> N COUNTY PUBLIC HEALTH SERVICES 0/0- <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) Cv� <br /> 304 E. Weber, Third Floor, Stockton, CA., 9528WIK4- <br /> DATE ISSUE=D <br /> (209) 468-344 <br /> NON-REFUNDABLE PERMIT l=XPIRES 1 YEAR FROM <br /> Application is hereby made to San Joaquin County for a permit to construct andlor install twork described. This application is made in compliance with <br /> Ehe <br /> San Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joagwn County Public Health Services,Environmental Assessor's <br /> Health <br /> or's Division. <br /> WELL Location <br /> I,+�Orsern120n I1 Cev+}vs.� Cross Street I1�4. Cew4"t City TMCY Zip 95376 parcel# C' <br /> PROPERTY Owner L� o� �� Address 325 C- 10-3. Ron T^,G Zip 45376 Phone#Z�9-83+- 120 <br /> Cordo VA Zi 45-1`12 Lic#737510 Phone#91b-638' I It <br /> C-57 Contractor Cos[.d� �n111» Address 36g2 OrSS Ckfs- City p <br /> t24„cl,° 7 2 11 Phone#516-6 3- 13eo <br /> jlavtid e:rae� t]r 17o Cit Cordova - Lic# <br /> CansultantlSubCantractorCaai•Her-F+ �» �„�• Address 3l�DGold G... Y <br /> Township Range Section <br /> GIS Coordinates:X 'Y E <br /> WORK TO BE PERFORMED <br /> DESTRUCTION (choose type bel } . <br /> (]NEW WELL I BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER") Oy OVER-BORE <br /> a SOIL BORING# a PRESSURE GRO T <br /> p WELL# <br /> 'Other: <br /> COMMENTS: <br /> TYPE OF WELL. INSTALLATION TYPE CONSTRUCTION SPECIFIC! iIONS MULTIPLE CASINGS? YES NO WELL CASING DIA: <br /> U MONITORING 0 HOLLOW STE=M DIA.OF BOREHOLE EE <br /> D EXTRACTION n AIR HAMMER/DRIVEN CASING THICKNESSE TYPE OF CASING: a STEEL 0 PVC []OTHER: <br /> p VAPOR p MUD ROTARY DEPTH OF GROUT SEAL I <br /> TREMIE TYPE TO BE USED: [I AUGERS HOS <br /> DEPTH IS <br /> 4 AIR SPARGE Il PUSH POINT GROUT SEAL PUMPED Y8s �]�o (NOSE' MOATEIMUM D TRAFFIC BOX o�L[]STOVEPIPE <br /> 0}) <br /> SOIL BORING [}HAND AUGER APPROX.BORING DEPT _ ZO��--b <br /> OTHER: []OTHER CONDUCTOR CASING PROPOSED? (fi YES,list specifications here): <br /> COMMENTS: f <br /> NOTE: OFFSITE BORI GS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I herebycertifythat <br /> have prepared application rll be done in erdanc tJoaquin Ordinances, <br /> and Regulatins o the San Joaquin County. Homeowner licensed agent's sgnatue certifieshefollwing: I certify that in the performance of the work <br /> persons subject to WOCOMPENSATION Laws of California" Contractor's hiring or sub- <br /> for which this permit Issued,!slab not employ p RKERS'/ f <br /> contracting signature certifies the fallowing_ ”!certify that in the performance of the wank for which this permit is issued,!shall employ persons subject to <br /> WORKERS'COMPENSATION Laws of Cafifomia." <br /> T PP. MUST CALL 48 WORKING HRS 1N AD(,VANCE/-POrR ALL;REQUIRED WSPECTIQNS. <br /> Title Je+^Lar {�P.c�iaS l5� Date 8 Z g~ r <br /> Signed x <br /> SEE SITE MAP l <br /> NIT IV WORK PLAN DATED: W � <br /> DEPARTMENT USE ONLY 01 <br /> E Date Issued rQ Areas <br /> Application Accepted By Final Inspection By Date <br /> __.Grout Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: •a /Z•4 f <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE=INFO AMOUNT REMITTED CHECK# REC'D BY DAT PERMIT 1 SERVICE R?QU��# INVOICE <br /> 2. W 3 -5 <br /> ,� <br /> i � <br /> C-57 LICENSED CONTRACTOR IVI[JST I69LICENSE&WO wRS'„CONiI?ENSATION'DECLAItA'I'�QN <br /> UNIT IV-6/23/99/sign bkpg/MI <br />