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B-11-1999 11 :ASAM FROM <br /> 0 <br /> WELL PERMIT APPLICATION FORM <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION ("PHS-EHD") <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3450 <br /> 1S' Ro0 C LA-A P'VA 12� <br /> ( NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Appilcation is hereby made to San Joaquin County for a permit to construct and/or install the work descnbed. This application is made in compliance with <br /> San Joaquin County DevelopQienl Title,Chapter 41115.3 and the Standards of San Joaquin County Public Health Services.Enviro mm sntoalHealth Division. <br /> 1 S"d 00 CAAA i n^w- 2.t, a !._ <br /> WELL Location <br /> R)I�c1n� ; �p_SS _Cross Streets QsCJ CrU✓�b�ty-=T----7� Parcel# <br /> __,--r <br /> \ �c, `Ciry\r�.r.�_LJi_Zip _Phoha# �D� •ci30'J <br /> PROPERTY Owner�.z.--Lr. �•-o��t- drew��OS.C��ni �/ if,�, <br /> C•57 Contractor- r r� �-•�\ •.� /dress <br /> o� � ��q city yy"I1tMLL ftp C45�3Lidt Phoneft `6 W <br /> H -fie PnonatF ll rir�l"SL11-+ssS <br /> Consultant/Sub Contractor ;,;_l,:t =�tlress .T... . T <br /> 5,J C.ry.,K,. ,Sten q Ot'+crk� t5t [��t JoSr Section <br /> GIS Coordinates:X�Y ,Township ange <br /> WORN TO BE PERFORMED <br /> NEW WELL/BORING(CPT.GEOPROBE.HYDROPUNCH,HAND-AUGER,OTHER-) S DESTRUC7I,ON OVER-BORE(choose type below) <br /> p SOIL BORING 12 )WRESSURE GROUT <br /> U WELLu <br /> 'Other. <br /> COMMENTS: <br /> TYPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br /> $-MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?Q YES Q NO WELL CASING DIA:__ <br /> .EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS TYPE OFE TYPE TO BE USED: Q AUGERS OHOSC <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE:OMAXIM,UMMFFREBEO-'F FREE-FALL is <br /> FE 0') <br /> 0 SOIL BORING 0 HAND AUGER APPROX.BORING DEPTH O <br /> 0 OTHER: <br /> CONDUCTOR CASING PROPOSED'— (if YES.list specifications here): <br /> COMMENTS �CLd6\ <br /> t^NA OS Rs <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS! <br /> I hereby certify that I have prepared this aDD�hon and that the wont will be done in accordance with San Joaquin County Ordinances.State Laws,and Rm k <br /> and Regulations of the San Joaquin County, Homeowner or licensed agent's signature certifies the following:"I certify Drat in the performance of work <br /> for which this permit is issued,I shall not employ parsons subject to WORKMAN'S COMPENSATION Laws of California." Contractor'ssub act fo sup- <br /> contracting signature certifies the following:'I certify Malin the performance of the wc&for which this permit is issued.I shall employ pe 1 <br /> WORK"COMP�ENSAIrIONws of California.' <br /> ANT MUST CALL d8 HRS IN ADVANCE FORALL REQUIRED INSPECTIONS. <br /> Signetl Title h_r sA �.�...�-r�ate \Y�\qc\ <br /> SEE SITE MAP IN UNIT IV WORK PLAN. DATED <br /> DEPARTMENT USE ONLY I' )A <br /> Application Accepted By <br /> ( P Date Issued &/�7/9`1 Area C2A 4C-M Co! <br /> Grout Inspection By <br /> Data Final Inspection By ate <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: ✓-tv 03(, LL-tLm U 1 <br /> FACY <br /> ACCOUNTING ONLY: I AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKWCASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE <br /> UNIT IV- 5/99 /MI <br />