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9-22-1999 4:00PM <br /> WELL PERMIT APPLICATION FORM <br /> UNIT IV <br /> SAN ,JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION ("PHS-EHD") <br /> 304 E. Weber, Third )458 Stockton, CA., 95202 <br /> NON.REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ade in <br /> Application is hereby made to San Joaquin County for a permit to Construct and/or install the work described. This application n Assessornntal H Health <br /> Division.wird <br /> San Joaquin Cou/nty Development Title.Chapter 9.1115.3 and the Stan dPPards of�San Joaquin County{Pudic Health Services,Environmental <br /> 14d4'0 <br /> WELL Lowtlone�2$ Mcs C Ve ' Cross <br /> t3 C.`?6 MO A\4 City �tDUUu_�, o(S219 Pnone# <br /> { Merrl L„.So.k7i9 ayS4ock*hh Zip <br /> �•1kx' '\u�YV.S 1 Address` <br /> PROPERTY ow/n�er t tkmr tht2zipg4SSSuc#44SI65Phonet4�5)3t 3'SSOD <br /> C•57 Contractor\mq iti_V% 0. Address qS� �OUJ C ��' City <br /> /� Sonoma Lic# Phone+s�'7c-1�g3S-485G <br /> rLWt�tOtt"'�4�VlbwtonE]��'0.�Adtlress7.-JO QQXI<��115 S}• City <br /> nsultant/Sub Contracto Range,_—Secticn� <br /> Y J Township_� <br /> GIS Coordinates:X�—= <br /> WORK TO BE PERFORMED <br /> p DESTRUCTION(choose type below) <br /> �vecW WELL I BORING(CPT, VIL BOHYOROPUNCH.HAND-AUGER.OTHER' p OVER-BORE <br /> Q PRESSURE GROUT <br /> p 5 IL BORING <br /> G# <br /> HELL# <br /> 'Other. II <br /> COMMENTS: <br /> TYPE OF WELL CONSTRUE CONSTRUCTION SPECIFICATIONS ���� <br /> DIA.OF BOREHOLE MULTIPLE CASINGS?U YES Ko WELL CASING DIA:_ <br /> 1IONITORING �lOLLOW STEMVC OTHER: <br /> EXTRACTION p AIR HAMMER/DRIVEN CASING THICKNESS SC'%-LV 0 TYPE OF CASING:TYPE TO BE USED: �f(UGERS pHOSE <br /> U VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL^'� <br /> GROUT SEAL PUMPED: ghes pN� (NOTE: MAXIMUM FREE-FALL DEPTH IS 10') <br /> Q AIR SPARGE a PUSH POINT N p �OLTED TRAFFIC BOX or I]STOVE PIPE <br /> Q SOIL BORING- a HAND AUGER CONDUAPPROX. BORING DEPTHS`'-- If YES,list specifications here):`— <br /> CONDUCTOR CASING PROPOSED?N ate_( <br /> OTHER: <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMIT otthe work <br /> I hereby certify that I have prepared this apptication and that Ne worx will be done in accordance with San Joaquin County Ordinances. <br /> S�t)]�{�La� and Rules <br /> and Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: "I car rify that in We perfonna•'S" <br /> contwhichracting signature certifies the following: '1 employ <br /> that in the peAormance a!the work for which this permit is issued.1 shall omploy subject to <br /> for Regulations <br /> this permit S issued,f shall not employ persons subject to WORKMAN'S COMPENSATION Laws of California.' Co ctor' hiring to su <br /> certi <br /> WORKMAN'S COMPENSATION Caws of California.' <br /> HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> T AP LI MUST CALL 48 <br /> Signed x <br /> Titl � e <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED <br /> DEPARTMENT USE ONLYO Area�, �(-,—���,/ <br /> Date Issued JJ Oate <br /> Application Accepted By / Final Inspection <br /> Grout Inspection By t '� na— Oate <br /> Destruction Inspection By _ <br /> COMMENTS/CONDITIONS: <br /> FAC# <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#ICASH RECEIVED BY �o / PERMITI�O CE�OUESLl Z�NUMBER 1NVOICI <br /> sol �5�1•r�' 13�' <br />