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M WELL PERMIT APPLICATION FORM 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 I 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 mate in compliance with <br /> San Joaquin County Development Title, Chapter 9-1116,3 and the Standards of San Joaquin County Public Health Services. Environmental Health Division. <br /> 749 E . Charter Way Grant St . Assessor's <br /> WELL Location y Cross Streit Gity StocktonZip 95206 .Parce!# <br /> PROPERTYOwner Darpetro ,t Inc . AddreA450E1Camino C;tyCeres Zip 953074hone: 537 - 0771 <br /> Gregg Drilling & T-est-ing , Inc _ , 950 Howe Rd . , Martin_ ez , Ca 9455315763T4U <br /> C-57 Contractor. � ,muss - ty - Lic# = loneA25 313 ' 5800 <br /> Calif . Geophysical Group P , O . Box 578341 95252 <br /> Consultant i Sub Contractor Address City Mode St 3Lic* Phone# 527 - 1247 <br /> GIS Coordinates: X , Y 5357 <br /> , Township ange Section <br /> WORK TO BE PERFORMED '— <br /> X )p NEW WELL / BORING CPT GEOPROSE, HYDROPUNCH , HAND•AUGER, OTHER*) D DESTRUCTION (choose type below] <br /> SOIL BORING ;� 2 p OVER-BORE <br /> "Other WELL # D PRESSURE GROUT <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> D MONITORING ❑ HOLLOW STEM DIA. OF BOREHOLE1 1 / 2MULTIPLE CASINGS? D YES 0 NO WELL CASING DIA: <br /> 0 EXTRACTION D AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING D STEEL D PVC D OTHER: <br /> D VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED, p AUGERS pHOSE <br /> D AIR SPARGE ff USH POINT GROUT SEAL PUMPED: D Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> X ;3 SOIL BORING n HAND AUGER APPROX- BORING DEPTH 1 n U f t . 0 BOLTED TRAFFIC BOX or D STOVE PIPE <br /> D OTHER:_0 OTHER 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 cenify 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 hirine or sub- <br /> contracting signature certifies the ;allowing : 1 certify that in the per;ormance of the work for which this permit is issued. I shall employ persons suhjecl to <br /> WORKERS ' COMPENSATION Laws of California. " <br /> THEA LICANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS, <br /> Vgnedx Title President Datc 8 / 28 / 00 <br /> SE SITE MAP IN UNIT IV WORK PLAN DATE <br /> DEPARTMENT USE ONLY <br /> Application Accepted By C2 rye 0 -mm�- Data Issued 9- 7 - Uy Area f� 7 <br /> Grout Inspection By Date Final Inspection By Date. <br /> Destruction Inspection-s'y to Inspection-s' pate (� 0 <br /> COMMENTS CONDITIONS• r9lG� <br /> II ACCOUNTING ONLY: AIDn FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED H C' /CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE I <br /> C.o 9/7/&_D S R# 0 4393 i <br /> C-57 LICENSED CONTRACTOR MUST SIGN LICENSE &NYORXERS ' COMPENSATION DFCLA' TION <br /> UNIT IV - 6/23/99 /sign bkpo/MI <br />