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k <br /> / —uI — ] <br /> W <br /> �r�� � WELL PERMIT APPLICATION FORM UNIT IV <br /> � �D <br /> �E " � SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> t JUL 2 1 2005 ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> t ENVIRpNMENT HEALTFt304 E. Weber, Third Floor, Stockton , CA . , 95202 <br /> 209 46449 <br /> PERMITISERVICES ) &-3 <br /> I NON-REFUNDABLE PERMIT EXPIRES T 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 /> Sidewalk of <br /> AsseWELL Location N r}f�l side ) erossstreetCharter W Stockton 95202 Parce '4734309 <br /> e MAX - Y Zip Parcel# <br /> PROPERTY Owner enet. o , Inc . AddressP • O . Box98O220 C,N . Sac Zip95798 Phane49166770819 <br /> C•57 Contractor Spectrum Address 2365 Wigwam Dr . city Stockt? 952Qi5# 5122 o11e#465 - 8712 <br /> Consultant / Sub Contractor CA Geophysical ( &pdgeI. P . O . Box578341 cit ModestoLi 6506R 2095271247 <br /> Rhone# <br /> GIS Coordinates: X , Y. Township Range.9 Section <br /> WORK TO BE PERFORMED <br /> J[NEW WELL / BORING ( CPT, GEOPROBE, HYOROPUNCH, HAND-AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br /> 0 SOIL 8 <br /> ELL ##%Wo, Y 0 OVER-BORE <br /> "Other. �6k(GY 3 2mndt 0 PRESSURE GROUT <br /> COMMENTS : <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> XLXMONITORING :1gt0LLOW STEM DIA. OF BOREHOLE 8w5 MULTIPLE CASINGS? 0 YES 30 NO WELL CASING DIA: 2 " <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS 40 TYPE OF CASING; 0 STEEL WVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 27 Ft . TREMIE TYPE TO BE USED: H AUGERS WOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: {fes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH 50Ft . N"BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 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 certify that in the performance of the work <br /> for which this permit is issued, f shelf not employ persons subject to WORKERS' COMPENSATION Laws of California." Contractor's hiring or sub- <br /> contracting sign tune certifies the following : 7 certify that in the performance of the work for which ;his permit i& issued. 1 shall emPloy persons subject fo <br /> WORKERS' CO 1PENSr1 TION Laws of califomin. " <br /> yy _ THE APPLIC NT UST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. c <br /> Signedp \ Title GA <br /> Date[ ���4. S <br /> SEE SITE M IN WORK PLAN DATED Oct . 16 , 2004 <br /> n ` / DEPARTMENT USE ONLY <br /> Application Accepted By //�C / � ilr�fP/,his-f ; <br /> ,Date Issued Area r�����65 /`yam i <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS / CONDITIONS: <br /> ACCOUNTING ONLY; AIOW PAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE I <br /> 35o / ap <br /> 503 279 ✓��� 399 C,VT,K 72- 5 0043239 I <br /> C'=S7 LICENSED. CONTRAC`ITOR MUST SIGN LICENSE & 1VOItIiERS ' ' C(jMZ'ENS 1TT01V DECLARATION <br /> ARATTON <br /> UNITTV - 6/23/99 /sign bkpg/MI COS Revu5Ur �exl*t7 - fir?5 - 09W <br />