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r,KUM <br /> P. 2 <br /> WELL PERMIT APPLICATIb F <br /> i! N ECRM w <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES p <br /> 304vIRONMENTAL E. Weber Third NEALTH Floor, StocktoO CAH S2HD) 'O2G�0 C a <br /> (209) 468-3449 ' 02 �'Pr�/�2��, <br /> NO Tor NLIABLE PERMIT EXPIRES fi YEAR FROM DATE ISSUEf) <br /> Permit <br /> AppliCBtivn is hereby made to San Joaquin CounnLy ty fora to construct and/or install the work:described. This application is made in <br /> San Joaquin County Development Title,Chapter 9-1115.3 and the Standards ofS anJ Joaquin County Public lieafth Services,Environmental co Health iwit 9n. <br /> WELL Location \3 b S p � � <br /> G1 <br /> 5 b -Cross Street City �° �o Zip t 5 3_,0 Assessor's <br /> Parcektt <br /> PROPERTY Owner C 4 o Sctiln Address t3 O Z it Z o°k- <br /> \t City zip�I S 3 1-Ph <br /> C-57 Contractor V W cu 1\:T1Address o 1,10 Ll l b City�•s-zip`s5 6$Lic#12"1o1 Phone# <br /> Consultant/Sub Contractor - II <br /> ddress City��_U phone# <br /> GIS Coordinates:X Y Township_ I Range <br /> Section <br /> WORK TQ BE PERFORMED i <br /> fl <br /> `4 <br /> ,NEW WELL f BORING(CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER") ;s <br /> 0 SOIL BORING# 0 DESTRUCTION(choose type below) <br /> I WELL 11 m 5 p OVER-BORE <br /> 'Other: ! j] PRESSURE GROUT <br /> COMMENTS: I <br /> 'TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIF CATIONS i <br /> WfuIONITORING d HOLLOW STEM �� DIA.OF BOREHOLE " `� MULTIPLE CASINGS? YES <br /> EXTRACTION 0 U NO WELL CASING DIA: <br /> AIR HAMMEPJORIVEN CASING THICKNESS 0 TYPE OF CASING: 0 STEEL PVC 11 OTHER: <br /> 0 VAPOR 1 MUD ROTARYmW l01 DEPTH OF GROUT SEAL_ It <br /> 0 AER SPARGE 0 PUSH POINT GROUT SEAL PUMPED; . TREMIE TYPE TO BE USED: �AUGERS f]H05E <br /> �1 Yes Q No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> Q SOIL BORING u HAND AUGER APPROX.BORING DEPTH 15 1 R.w q a-s p BOLTED TRAFFIC BOX of <br /> U.4, ?, p srovE FtaE <br /> fl OTHER: OTHER w leo t <br /> CONbUCTOR CASING PROl�OSED? nro(if YES,list specifications here): <br /> ii <br /> COMMENTS: <br /> it <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby certify that I have prepared this appliodtlon 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: 41 certify that In the performance of the work <br /> for which this pen»it is issued,f shall not employ persons subject to WORKERS'COMPENSA,VON Laws of Caflfomia." Contractors hiring or sub- <br /> contracting signature Certifies the following: "f certify that in the performance of tha work for which this permit is issued,I shaft employ persons subject to <br /> WORKERS'COMPENSATION Laws of Cafifgmia." <br /> TH i� f ANT BUST9A 14'' <br /> 1N_ ORKM G HRS IN ADVANCE , I, . .. .`L REQUIRED INSPI=CTEOIVB. <br /> . .....NCE�fwOl, AL.._.. <br /> Signed x Title 0�'SLS v�Il 'r <br /> a Date � <br /> I� <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED: <br /> DEPARTMENT USE ONLY �l <br /> Application Accepted BY---L Date Issued t a to <br /> Area <br /> Grout Inspection By Datelo 1(7 l q CIO Final tnsp®otipn By <br /> Date Zc <br /> Destruction inspection 8y Date <br /> COMMENTS I CONDITIONS: it <br /> ifJ0 - <br /> ACCOUNTING ONLY: AID•k <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE I� PERMIT/SERVICE REQUEST# INVOICE <br /> X701 .oa I � y�u (,� to o0 P-,", ZI <br /> :.. . -..-.'� S CQ 'ENSATION D CLARATxQN <br /> ur�xr ry-bizsi 9� b�N��CT��MUST SIGN:t.TC��S�.��Q: ......._ <br /> i <br /> I� <br />