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- 11/08/99 12:03 FAX z <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHQ) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> Ngjj4tZMN0ABLE P MIT gMIRFA 1 YEAR FRW QAT11 <br /> Appiicatim u he+eby made to San Joaquin County for a permit to construct andlor Installtits work described This application Is made in compliance wife <br /> San Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmentei Health Divtslon. <br /> Assessor's <br /> WELL Location 2 4 3 2 3 N W Y 9 9 -crass.Sheet b—lu!t t _City A C3 1"P Q_ Zip Parceltt 00 5'_I�Q-19 <br /> Pi opvtTY Owner 131 Cbl fR r S I i 9 h, Address F 0 $ 21-3 5 oily Lotti zip 9- 5241-Phone# -29 2 <br /> C-57 Contractor V+W 0 r i I1 i M g t M a Address P O 3 5 C,ty i o Vi S zip L45-RILi-.# !094 PnonoAllf 993-T 5S <br /> SgMidolm,Sub Coptractar 4�$ hYl� rilPKt raes (1 _ __Citi �G�! S$S�7 Piton®a(,516)354-32 S0 <br /> u ttY'it--� <br /> GIS Coordinates:X Y Township Rsrrge Section <br /> WORK IQ 11E PERF RMED -- <br /> 0 NEW WELL/BORING(CPT.GEOPROBE, HYDROPUNCH, HAND-AUGER,OTHER-) a DESTRUCTION(choose type below) <br /> SOIL BORING it__ f�-I [I OVERBORE <br /> 'Other: <br /> vVELL d Q PRESSURE GROUT <br /> COMMENTS: <br /> TYPE Qf INSIALLATION TYPIg CONSTRUCTION P I TIONS <br /> 0 MONITORING HOLLOW STEM DIA.OF BOREHOLE NA MULTIPLE CASINGS?[)Yr,-r. XNO WELL CASING DIA NA <br /> ,p EXTRACTION AIR HAMMERIORIVEN CASING THICKNESS NA TYPE OF CASING: (]STEEL p PVC 0 OTHER' _4A <br /> B VAPOR p MUD ROTARY DEPTH OF GROUT SEAL _9I-fttt TREMIE TYPE TO Bar USED: n AUGERS *OSE <br /> 0 AIR SPARGE 4 PUSH POINT GROUT SEAL PUMPED: XYas 0 No (NOTE: MAXIMUM FREE-FAIL.DEPTH IS 30'} <br /> XSOX BORING p MANOAUGER APPROX.BORING DEPTH_ 9O-fttt 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> d OTHER- n OTHER CONDUCTOR CASING PROPOSED? 140 <br /> (if YES,list specifications hers):__, <br /> COMMENTS: SCOP.0 0 war 1{#0 01 f rl q N ih P f WoF it ri ! Ell I6 9 <br /> ---Work PL44a m pits-E` o <br /> NOTE: OFFSITE BORING$ REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby=dify that 1 have prepared this application and that the work v4II be done in accordance w+tt+Son Joaquin County Ordinences,Stale laws,and Rules <br /> and Rogulalions of the San Joaquin County. Homeowner or kerreed agorrt s*%Fw tttne csrtltles The following: -1 c"y that In the performance of Me work <br /> for Which 018 perntft Is Issued,I ah"not employ persons subj"t to INOA PERS'COMPENSA770N Laws o/Catlltbmla" ContraGor's hiring or sub- <br /> 00ntn0Cf g signature co tirms the fnNor ft: 1 e&fMf that In the P&db,nrranW of lits W4Wk hr Mlirh this Permit is issued,I shah employ jowsons subject to <br /> YKIRKERS'COMPENSATION L of Calllorms." <br /> T E.tpPLC MIJST,If1�;;41�,': ! 1C HR E[Y1/9� (%e CA.Rpm <br /> Signed x Title <br /> .Lld,L„�L . Date IIJI jig <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED: _ <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Dale Owed <br /> Grout Inspection ay Dete Final inspection By Date <br /> destruction inspection By Dale <br /> COMMENTS t CONDITIONS: L.O. S&,& <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT RENIITTEO CHECK RECD IFY DATE rErlINIT/86RVICE R@QUEST o INVOICE <br /> Also <br /> CIr�rT <br /> UNrT tV-6/23/99 leign bkpg/ilitI <br />