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Jr, Lu, Jou 1cJ: l� ctJy•;po�•,,;,; rlr In rL.t.,ur� �� r-iuG rJ� <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 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 GMK RD SF1 riip pRCCERSE $,Q�� frt <br /> Cross Street ot-T 0• _City oC, Zip 9Z 3 Parcel# <br /> PROPERTY Owner 5 FPP L.1 ' -Address 1I YW�1 s CoU�1( R'A• City Dft& —__ZiP9'Zg g Phone# ? S- <br /> �pn/�� 5 Llc#S�2(,'$ Phone*C-oR V`a7(l <br /> C57 contractor SP I��M EKTIxt— Address 23 5 t�tGt�IAM AR• City�otKtrr� ZiP9 soy <br /> Consultant/Sub Contractor 4 FAJcKiG Address'b$t)CA�ST4[UMili79CjoRAd96 <br /> GIS <br /> Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> VEW WELL/BORING(CPT,GEOPROSE,HYDROPUNCH, HAND-AUGER, OTHER-) 0 DESTRUCTION(choose type below) <br /> p 501L BORING# OVER-BORE <br /> WELL p PRESSURE GROUT <br /> Jr <br /> 'Other: <br /> COMMENTS: <br /> TYPE OF WELL IN TALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING HOLLOW STEM DIA. OF BOREHOLE I O" MULTIPLE CASINGS?IES ONO WELL CASING DIA:Z�r <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS 5•:11.40 TYPE OF CASING: 0 STEEL t4,VC OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEA 3o go TREMIE TYPE TO BE USED: AUGERS pHOSE <br /> AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: Yes 0 No (NOTE: MAXIMUM FREE-FALL D-PTH IS 30') <br /> SOIL BORING 0 HAND AUGER APPROX.BORING DEPTH 50-65' 0 BOLTED TRAFFIC BOX or eSTOVE PIPEr <br /> 0 OTHER:_0 OTHER CONDUCTOR CASING PROPOSED? YES (if YES,list specifications here):�SlEr <br /> ,5T-SF:(, CQt�hur-Tg& CActcl� rd ss' 100 A of r � ��� FnR 3 •,JEu.r. 8 R <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <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: "1 cert;fy that;a the performance of the work <br /> for which thls perm;t/s issued,/shall not employ persons subject to WORKERS'COMPENSATION Laws of California." Contractor's hiring or sub- <br /> contracting signature certifies the following: "I certify that in the perfarmance of the work for which this permit is issued, I shall employ persons subject to <br /> ENSATION Laws of California." <br /> woRxERs'CoMPTHE�UNITJV INSPECTOR 481NORKING`HRS IN ADVANCEfO.RALL,REQLi►RED.IIVSP�CTIONS. <br /> Signed x TitlelCompany QIGo�£�T C-rEoGoG����G Fk. «��6 Fie'`1e1�.E <br /> Print Name� � .t1 G`9 T o'(� Date 3 1 Z� F s �I rntr� <br /> r+��rI ��c Iy,.,i�i �yy.�(�yt t '-" (�9 t I } I tJ ��, r� y1 <br /> Iry__r l P�IYt�I' h�„tr1;�IM��n?lu����'f,1ryy'�'i YY.I;lf`.�;'�P AI`�jl�Ed '�.��"�. '.il 1 t OEM <br /> �i7Fl�•,�a!- <br /> Nt un1.:.,�1..J-.•Mwu..,l, �:IWl141M N Nfl(�I�+1W+.Ji�.uSJOr—��LLi .+...G n <br /> DEPARTMENT USE ONLY <br /> Application Accepted By G moo. Date Issued `1 �i' (J U Area <br /> Grout Inspection By <br /> a a Final Inspection By Date_ <br /> Destruction Inspection By Date _ <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 1/18/2000 <br /> MAR 20 '00 10: 15 2094683433 PAGE.02 <br />