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WELL PERMIT APPLICATION FORM UNIT IV <br /> SAHEALTH UNTY CVIS ON (PHS-EHD)HEALTH S <br /> ENVIRONMENTAL <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 ORIGINAL <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDmade <br /> Application is hereby made to San Joaquin County fora permit to wnstruct andlor install the work described. This application is iron a ntals ea compliance with <br /> San Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health;C Wion. <br /> a�ri7`�5 _Cross Street City df5 ',y,.�+µ�Zip �U(tlt <br /> WELL Location-- Zip Phone# L, — <br /> �{' /- city_ <br /> PROPERTY Ownerli 1�44Uh^ wU' 1 abn <br /> Address Dpp //�� // �j-� <br /> �, I', Address <br /> �� FIOttZ K� City i•1C Zipvauc# GVW Phone#JIC <br /> C-57 Contractor Phone#S�-b76- Z <br /> CCq30 ! City Lr <br /> 1 1' t�Vl✓l/tll1Mh �` Addres Y,ry-W9Z <br /> Consultant/Sub Contractor 12uY ,,i sh 550 Vr Section <br /> r Township,_—Rang�__� <br /> GIS Coordinates:X_�'Y— <br /> WORKTO BE PERFORMED 0 DESTRUCTION(choose type below) <br /> 0 <br /> NEW WELL/BORING(CPTVEOIL BORING# PUNCH,HAND-AUGER,OTHER OVER-BORE <br /> a PRESSURE GROUT <br /> 0 WELL# <br /> 'Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALS N TYPE CONSTRUCTION SPECIFICATIONS <br /> HOLLOW STEM DIA.OF BOREHOLE�Ll nim MULTIPLE CASINGS?p YES 0 NO WELL CASING DIA:_ <br /> U MONITORING 0 TYPE OF CASING: 0 STEEL a PVC 0 OTHER: <br /> g EXTRACTION O AIR HAMMER DRIVEN CASING THICKNESS TREMIE TYPE TO BE USED: GAUGERS <br /> �AOSE <br /> MUD ROTARY DEPTH OF GROUT SEAL lSn� <br /> p VAPOR � GROUT SEAL PUMPED: �'es p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 AIR SPARGE 0 PUSH POINT BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> ^SOIL BORING O HAND AUGER APPROX.BORING DEPTH ISTD - 0 <br /> CONDUCTOR CASING PROPOSED? OU (if YES,list specifications here): <br /> p OTHER: 0 OTHER <br /> row <br /> COMMENTS: 2 <br /> ate Laws <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby certify <br /> nd tons a the San Joaqu n CJIB ounty.11 Homeowner or III <br /> sat the ed gek will nt s signature certif es theuin Fou <br /> tfo and Rules <br /> San <br /> 9l certify ntha0t in'the perfotrma ehiring or <br /> e of the work <br /> for which is er Is s ue ds Itcontracting signatu ecce ifies the fol ow nemploy <br /> g tl certify that nothe performance of the work for whiichSATth s permit ssubject to WORKERS' IONsissued 11 shall employtpersons subject to b <br /> WORKERS'COMPENSATION Laws of Caldomra <br /> Signed z r l^C <br /> Title � !_ Date l Z'fJ� <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED: 0 " A" <br /> DEPARTMENT USE ONLY ? 0 <br /> �[�y/�// Date Issued ✓ Area <br /> Date —Final Inspection By <br /> Application Accepted BY C�.A/' ' '-��C�rc���� <br /> Grout Inspection By 0 nK+yN� <br /> Destruction Inspection By <br /> Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 535-5 <br /> 5. . 0 ��.$ <br /> VNIT IV-6/23/99/sign bkpg/MI <br /> WObj WVVS' LL 666L-60—ZL <br />