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WELL PERMIT APPLICATION FORiv, 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 /> y7 5 . EL DSR Poa lvy AVQ • �; ISZo Assessor's <br /> 31 <br /> WELL Location c + Cross Street % 1 dor AD o City STac.K Ton Zip Parcel# <br /> /� <br /> C D <br /> PROPERTY Owner V/AJJ DE (n 01 C /1-. , Address Pt a • Oo7C 8137 City SToCKTon Zip95Z o I phone# Z `,ll ' % Y 3y2- 1 <br /> W EgT 116Z M4T AIIhG1I0 <br /> C-57 Contractor DArL1. inG Address9133Fi1'ZcU010 S+ L CitycaAD " Zip957 LLic# 55Y977Phone# 916 - b35 - 7Z7(p <br /> � Ina <br /> Consultant / Sub Contractor Adu An< ea) Qa `'ey Address YQWr N , Wil9' r. City STo` Xyw Lic# 63oZLePhone# Zo9 - t/ b 2-/oil, <br /> GIS Coordinates: X., Y , Township Range Section <br /> WORK TO BE PERFORMED <br /> NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') 6 DESTRUCTION (choose type below) <br /> 0 SOIL BORING # 0 OVER-BORE <br /> WELL # MW ' 5t AA W ' br MW " t MVv aPRESSURE GROUT <br /> 'Other: <br /> COMMENTS : Muj, 5 wo l br� DEfQ SCrF � wieb M oniTor , 'nc1 tvC ?_ L o.} Hftox , So F> E -+ <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING iOLLOW STEM DIA. OF BOREHOLE 8 MULTIPLE CASINGS? 0 YESXO WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS S� � vle TYPE OF CASING: 0 STEEL LIrC 0 OTHER: <br /> 0 VAPOR p MUD ROTARY DEPTH OF GROUT SEAL IS FELfi 6Ys TREMIE TYPE TO BE USED: VUGERS 0HOSE <br /> AIR SPARGE p PUSH POINT GROUT SEAL PUMPED: Ares 0 No (NOTE : MAXIMUM FREE-FALL DEPTH IS 30' ) <br /> 0 SOIL BORING p HAND AUGER APPROX. BORING DEPTH 4 o F�10 BOLTED TRAFFIC BOX or p STOVE PIPE <br /> 0 OTHER:.0 OTHER CONDUCTOR CASING PROPOSED? A! n ( if YES , list specifications here): <br /> COMMENTS : M W �V W71I b DEE .p sca kit R 3 F££ + 6A/19 i' l C, A -f los 7r, <br /> £ 5ro �J -- sial r=f " LCRAce Grcxtc 46S Fez- <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: "I certify that in the performance ofthe work <br /> for which this permit is issued, I 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 performance of the work, for which this permit is issued, / shall employ persons subject to <br /> WORKERS' COMPENSATION.Laws of California. " <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed x Title/Company TRONECTrA 9 S <br /> Print Name IiM 07N , J. Cye ) 1A9AQ Date 14wo0 <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED : 9 -Z9' -oa <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Issued // -30 '- OD Area O '7 ,K'(= <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Dale <br /> COMMENTS / CONDITIONS : 1911 MWS ar-e CPA Stlp is tip ri;" Caellas . $ LVfg 4/0c-� Ge // W0 ,7 <br /> N <br /> ACCOUNTING ONLY: AID# FACAE <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT I SERVICE REQUEST # INVOICE <br /> 3 " 1 8 f 8 Y — / y .L So V O 00 SR# 00 -U (62,57 <br /> 1/18/2000 <br />