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n _ <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION ("PHS-EHa") <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3450 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 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 /> Assessor's <br /> WELL Location 2 4.313 N. H WY 9 9 Cross Street TA NA NI R R City ALA M PQ Zip Parcel# 00 5- 16)0-19 <br /> PROPERTY Owner $AG H I TA I1 S 1 N C-H Address P.O. d t7 X 14 35 City Lo 01 Zip 952'11 Phone# 3 3 2 091 <br /> 0-51 (916) <br /> C-57 contractor V4 W 0 RILL1 N Address P-0- 509 16 CIryIS LE TO N Zip95641 Lic#37.990 Phone# 341-4.100 <br /> .TO 59PH RA 14ACrE PIC. 0OX 869 R-0. 9I6) <br /> Consultant I Sub Contractor R A M A Cr F- ENV 1-0._ - Address RA N G H Q M V ii l E T A . .City 9 $ Lic# 5 8 5_Phone# 3 5 -3150 <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> ,...� � pERt=OIgMED <br /> NEIN WELL/BORING(CPT.GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') 0 DESTRUCTION(dwoae type be" <br /> 0 SOIL BORING# II OVER-BORE <br /> WELL#—M W-i 2 a PRESSURE GROUT <br /> 'Other: <br /> COMMENTS: * 3 Ct4- 5tTe MONITaRtNCr WELL <br /> TYPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING [[HOLLOW STEM DIA.OF BOREHOLE 2'IN MULTIPLE CASINGS?0 YES §NO WELL CASING DtA:2'1N <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS SC It 44 TYPE OF CASING: a STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL; 6 6- F Y TREMIE TYPE TO BE USED: J AUGERS [[HOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: r Yes [[No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> [[SOIL BORING 0 HAND AUGER APPROX.BORING DEPTH 90-FT E BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER: CONDUCTOR CASING PROPOSED? 140 (if YES,list specifications here): <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS1 <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 than In the performance of the w * <br /> for which this permit is issued,t shall not employ persons subject to WORKMAN'S COMPENSATION Laws of Callibmla." Contractor's hki g or sub- <br /> contracting signature certifies the following:'I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to <br /> WORKMAN'S COMPENSATION L s of California." - <br /> 'THE PPL NT MUST CALL 48 HRS IN ADVANC FOR ALL REQUIRED INSPECTIONS. <br /> JAIA <br /> Signed x :'Title :" bate f1b�A>� <br /> SEE SITE MAP IN UNIT IV WORK PLAN. DATED MAY 211-000 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Issued^ DO Area <br /> Grout Inspection By pate Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS. <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHEc ASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE <br /> ? 049o)4 Y&*7 <br /> UNIT IV-6/1/99/sign bkpg/MI <br />