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12-10-1999 12:33PM FROM P. 2 <br /> • • <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 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct andior 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 Sen Joaquin/County Public <br /> rr``Health Services, Environmental Health Division. <br /> WELL Locetlon PBT Cross Street CN.Qir�1'iA/AnCgy. Zip`�p� Par elk Assessor's <br /> PROPERTY Owner tom' Sf 277TSgrpq�rose`/,,,,,� QC�If,-,r4 *J& city lZ*C Zip rSq76Phone# <br /> C-57 Contractor—Qr I ��/) Address /-0 #a4 -14*-b/� City��l e-Z-Zip�y cx t�4� �Pnoneva9�S%3/3-SSfflD <br /> Corwultant!Sub contractorAd <br /> dress_ ��3X / city" y1LYdK Phono# /`i/o Slat S33Z <br /> GIS Coordinates:X 1O$'7S7b{' ,Y 430 23srkr 7 Township S Range Section 3� <br /> WORK TO BE PERFORMED /�^ —' <br /> 0 NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) �0.DESTRUCTION(choose type below) <br /> 0 SOIL BORING# / __ ,0 OVER-BORE <br /> 'Other: _rLI2 P2 IN-e Q7ov S P 7r� p fFLIAA/,J1�/Ut �S\6.i�_FSSURE GROUT <br /> COMMENTS: � r <br /> V/ IPJ J�A/N S r1�rL,ap.N ,Pok7(, 3 1 $ C L.O r�AJ,22o r77__p.���3 1�__ �63Qao/� 9 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECiFICAT10N3 p �IriG7/ } it <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS? YES ONO WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER)DRIVEN CASING THICKNESS rr TYPE OF CASING:' STEELJ��/PVC 0 OTHER: S' <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL � TREMIE TYPE TO BE UX <br /> ED AUGERS OHOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> 0 SOIL BORING 0 HAND AUGER APPROX,BORING DEPTH /OO BOLTED TRAFFIC'�OX or 0 STOVEPIPE <br /> ,BOTHER: OIJ OTHER S�2�..4a(oW CONDUCTOR CASING PROPOSED? <br /> (it YES,list specifications here): <br /> 0A tLele AMC AA <br /> S � <br /> COMMENTS: QdfjORyS` J /e Amr A,1,9;,(Ad4e lue <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR FNrRtIACHMENT PERMI S <br /> I hereby certify that I have prepared this application end 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: 1cerf/ty that Irt the performance of the work <br /> for which this permit is issued,/shall not employ persona subject to WORKERS'COMPENSATION Laws of Caufomli Contractor's hiring or suG <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 /> WORKERS'COMPENSATION Laws of CelifoW." <br /> -._ <br /> .: „ .��.. .: .... In <br /> Signed x Titled 7�Date 2 13 C <br /> SEE SITE MAP IN UNIT 1V WORK PLAN DATED: <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Issued gran <br /> Grout Inspection By. Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> �.�.r <br /> UNIT IV•6/23/99/sign bkpg/MI <br />