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B-06-1999 12_SOPM FROM A P_ 2 <br /> All <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICE,-'1 1't <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHDy- <br /> 304 E. Weber, Third Floor, Stockton,,�CA.,052021 : S 4 <br /> (209p 468-3449 -, '` ' ) "'I <br /> ` t <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/4r 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 /> elp wE�7 Lf� Assessor's <br /> WELL Location . �V,sT LANG cross SStreeet =2A 1, nF- 4V-City �✓/C<�(%cfl Zip 5Z„S Parcel# <br /> PROPERTY Own//e��r ��fJ DE 7� � C/�-t rAjddress Pi'V- boy- l l(�'7 City�r4C Zip 5Z 0 Phone# AA q J5-3 7�1 <br /> C57 Contractor J7 ,G. , Address 7 p 6S M, b p kp�i 5rKwin Zipg5ZAS Lic# btu ZZ Phone# ZoCj-4 b' -/4,0(p <br /> ,�2 F <br /> Consultant/Sub Contractor�/)V,�G�Q[3 AaII <br /> dresscX��J S„it E h City. Pl�lr1 Licit �Z77Phane#.7��- �9 b ©3%� <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED"Sf <br /> NEW WELL/BORING(CPT, GEOPROBE, HYDROPUNCH,�A(�D�,U ER,OTH R') p DESTRUCTION(choose type below) <br /> Q SOIL BORING# F-/. P 7- I'"i /4� I3 5 Ip a OVER-BORE <br /> �]WELL# T� r r-•- ' <br /> [j PRESSURE GROUT <br /> Other. <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?0 YES 10 WELL CASING DIA:N <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS J�TYPE OF CASING: 11 STEEL a PVC 0 OTHER: <br /> o VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL-&,A) &P f TREMIE TYPE TO BE USED: 0 AUGER$ �SE <br /> a AIR SPARGE USH POINT GROUT SEAL PUMPED: a Yes�o (NOTE: MAXIMUM FREE-FALL DEPTH I"S 30') <br /> . IL BORING 0 HAND AUGER APPROX.BORING DEPTH ZS ! Q BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER: CI OTHER__ CONDUCTOR CASING PROPOSED? NI_(if YES,list specifioations here): <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: "!certify that in the performance of the work <br /> for which this permit Is issued,1 shall not employ persons subject to WORKERS'COMPENSATION Laws of California_” Contractor's hiring or sub- <br /> contracting signature certifies the following, "l certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to <br /> WORKERS'COMPENSATION Laws of California." <br /> HE APPLICANT UST CALL 48 HRS IN ADVAN FOR ALL_R/EQUIRED INSPECTIONS. �f <br /> r Signed x Title r t# �e oy,5 -Date--Q&/ J <br /> SEE SI4/ AP IN UNITIV WORK PLAN DATED__-©�/ <br /> DEPARTMENT USE ONLY <br /> Application Accepted By v 1t,-F G�,� Date Issued Area O ��- <br /> Grout Inspection By Date Final Inspection By Date <br /> Oestruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> FAC# <br /> ACCOUNTING ONLY: AID# �� <br /> PE CODES FEE INFO AMOUNT REMITTED Cmi&"''�1CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> L CI 1��f; SR# 0 <br /> C-57 LICENSED.:CONTRACTOR MUST SIGN:LICENSE'&gD'OM.K ,S'.COMPENSATION DECLARA`ION <br /> UNIT IV-6/23/99/sign bkp9/M1 <br />