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rur t <br /> 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 made in compliance with <br /> San Joaquin County Development Title, Chapter $-t t i5.3 and the Standards of San Jeaeuin County Public Health Services, Environmental Health Division. <br /> 749 E . Charter Way Grant St , Stockton 95202 Assessor'147 - 343 - 09 <br /> WELL Location Y Crass Street City Zip Parcel# <br /> PROPERTYOwner BenetorIne . AddressP • O . BOx 980220 City W . Sac Zip 95798 Phone"91 667 7081 9 <br /> c-57 cont actor j%j§XXX Spectrum Address 2365 Wigwam Dro cit tockto> ip 9522i5 5122 �Pone# 465 - 8712 <br /> Consultant / Sub Contractor CA Geophysical ( c'qWr�,Js P . O . Box 578341C,tyModest9,,, 6506R&hone#2095271247 <br /> GIS Coordinates: X Y_ Township - Range Section <br /> WORK TO BE PERFORMED -- - <br /> 0 NEW WELL / BORING ( OPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER") p DESTRUCTION (choose type below) <br /> 0 SOIL BORING # 0 OVER-BORE <br /> ELL # MW- 0 PRESSURE GROUT <br /> `Other Pin ] I Ot9 AS <br /> #r <br /> Au er <br /> COMMENTS : <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> KRMCNITORING W�fOLLOW STEM DIA, OF BOREHOLE �MULTIPLE CASINGS? 0 YES ffNO WELL CASING DIA: 2 rr <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS 401j TYPE OF CASING; 0 STEEL NjeVO 0 OTHER' <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 27 Ft . TREMIE TYPE TO BE USED 0 AUGERS XWOSE <br /> p AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: X[Kyes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 309) <br /> 0 SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH_,5,0_ Ft BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> p 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 pertarmance 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 s re cerfitie5 the following : "I certify that in the performance of the work for which .his permit is issued. I shall employ persons subject to <br /> WORK ' COMP NSATIONLaws of California. " <br /> `\ THE APPLICANT M ST ALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS . <br /> Signed x• ` ` t Title 61101 - Datc 4fti/ wT- <br /> SEE SITE MAP dVj WORK PLAN DATED Oct . 16 , 2004 <br /> A / DEPARTMENT USE ONLY <br /> Applioation Accepted By /vvr C„fl/te/s� h Date Issued 7 /9 0f� /6/.r� <br /> Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Dote <br /> COMMENTS / CONDITIONS: <br /> ACCOUNTING ONLY; AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#ICASH RECEIVED BY DATE PERMITI$ERVICE REQUEST NUMBER INVOICE <br /> •3308 398GSR# 06y3121p <br /> C=57 LICENSED? CONT'RACT.0 1VlUST-SIGN LI_CLNSE & 1GORIT RS' CO.MPENSArflON DECLARATION <br /> UNZT TV - 6/23/99 /sign bkpg/MI <br />