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i ` <br /> 2-10-2000 11 :24AM FROM P. 1 <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICE` �'�2 <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 /> pglication 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 /> ;an Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services.Environ <br /> Assessor's Q rtal Health <br /> Diu <br /> YELL Location <br /> t {ti;:7� IZcQ. Cross Street a`Y', � � City I��� Zip Gk _,Parcel# <br /> PROPERTY Owner �•� <br /> fN k. iZ vS Address "`� `_r �.�,e�Z City Zip C i4- Phone# <br /> J 4� Address _2 i Tw sL AV. City �I,!2-`yw(�A&`l 4C I Lic# 5£666�Phone#CSro)3� <br /> ,.-JT Contractor GtLrt� iti�l�t� Cv . <br /> t u„In �•,c; ,. t fid!c� 0<�cl�y t Phone#C�i <br /> ]onsultant/Sub Contractor-61 L« C AddressZ>'u <br /> ;aIS Coordinates:X <br /> Y Township_ Range_ Section <br /> VYORK i'O BE PERFORMED <br /> OESTRUCTION(choose WO below)_i 11 <br /> 4 NEW WELL I BORING(CPT.OF-OPROBE,HYDROPUNCH,HAND-AUGER,OTHER") Z wew j--,20:60 ER-BORE(,-AW � y <br /> Q SOIL BORING# (,;eve---4 ;0 PRESSURE GROUT <br /> (]WELL# p1nW-G� J -I ).-t stv t t1� <br /> *Other: -3 <br /> COMMENTS: /`G� C�I 4A,,&42, <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION—SPECIFICATIONS <br /> ILTIPLE CASINGS?(j YES Q NO WELL CASING DIA <br /> p MONITORING Q HOLLOW STEM DAA.OF BOREHOLE TYPE OF CASING: U STEEL Q PVC []OTHER: <br /> Q EXTRACTION p AIR HAMMERIDRIVEN CASING THICKNESS TREMIC TYPE TO 13E USED. a AUGERS CHOSE <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL <br /> fl AIR SPARGE Q PUSH POINT GROUT SEAL PUMPED: 0 Yes Q No (NOTE- MAXIMUM SFREE-FALL IC BOXDEPTH 1]STOVE P P3 o') <br /> U SOIL BORING 0 HAND AUGF-R APPROX,BORING DEPTH Q <br /> U OTHER:__O <br /> OTHER CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> COMMENTS- Via <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCRO I S <br /> repared this application and that the work will be done in accordance with San Joaquin County Ordinances,State laws,and Rules <br /> I hereby certify that I have p <br /> and Regulation'of the San oa uinred County. Homeowner or licensed agent's signature certifies the following. "I certify that in the performance of the work <br /> for which this permit is issued,I shalt not employ persons subject to WORKERS'CpMPENSRTION Caws of Califomfa^ Conuactot s hiring t sub- <br /> contracting signatute CWtifiea the following:'t certify that in the performance of the work for which this permit is issued,t shall employ persons subject to <br /> WORKERS'COMPENSATION Laws of Califomia.' <br /> CALL THE•UN1TN IMSPECTOR 48 WORKING HRS IN ADVANCE--FOR-ALI� REQUIRED INSPECTIONS. <br /> Signed x� Tdte/Company <br /> Print Name <br /> ./..-.r.........�.....__._�._tiM.�.M'.. ... ... �..-. . - /�. � !:..;-:`5..�-+.•Y,y...:ti a:��J y'i� yiy_?M <br /> Date ` nn � • <br /> 4- .. � 'yP....�A � ?i!.L'J�1�EI� 'tinkir•r.•i :r!., <br /> S1=E SITIE P fiV�"`til � :W 7EtE'C 3, J <br /> DEPARTMENT USE ONLY <br /> Date Issued I b Area <br /> Application Aocey�ted$Y date 3 O <br /> Grout Inspection By Date Final Inspection By <br /> Destru�n trnspection By Date <br /> COMMENTS1CONDMONS: <br /> 7 ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 350 z 6C'? 00 OIC 4Z <br />