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r. ..a <br /> 9-22-1999 d:OaPM FROM ���� COPY... �. ,C• {I� <br /> WELL PERMIT APPLICATION FORM <br /> UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION ("PHS-EHD") ON <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3450 <br /> NON-REFUNDABLE PERMIT EXPIRES—1—YEAR <br /> FROM DATE ISSUED (y <br /> de <br /> Application is hereby made to San Joaquin County for permit to Standards <br /> s o and/or install the work County <br /> ublic This application on e incompliance <br /> H Division. <br /> _�y <br /> San Joaquin County Development Title.Chapter 9-1115.3 and the Standards of San Joaquin Cou�tO Lk t��P Services,,EnvuASSA 1 He IN Oi/vi-0sio�n. (/ <br /> t OAT 1� T Si" City .L,G <br /> WELL Locationt, 494 ,Cross Street F <br /> p 20Da"124 city HDRSW _zip77056 Pnone#5S1 6N5 9306 <br /> PROPERTY Owner E i an Ena rl a lG Address lq$ Y cm,Martimz zip12g Lic# 56 69o7PhonO19J 5 313-ss�d <br /> l7Y Wdt Z,Vt�TtU Address 950 HD we Rd � <br /> C.57 Contractor_ }� Lit# pnpne#707"935'f{8SO <br /> Addessa701'erk"A) 57. City ctn Q <br /> Consultant/Sub Contractor_�y^bPiA Fi 1�V. Range Seuicn� <br /> —J Y _,Townships-- <br /> GIS Coordinates:X <br /> WORK 70 BE PERFORMED T� <br /> p DESTRUCTION(choose type below) <br /> rNEW WELL f BORIN (CP7 EOPROBE.HYOROPUNCH.tt�1AND-AUGER.OTHERSOPT 0 OVERBORE <br /> SOIL BORING 56'45g'fb�-U (I PRESSURE GROUT <br /> WELL It <br /> -Other: <br /> CC`MMENTS: <br /> TYPE OF WELL CONSTRUE CONSTRUCTION SPECIFlCATION <br /> HOLLOW STEM DLA-OF BOREHOLE_MULTIPLE CASINGS? YES �(NO WELL CASING DIA:__ <br /> Q MONITORING O TYPE OF CASING: 0 STEEL Q PVC G OTHER: <br /> g EXTRACTION 0 AIR HAMMEPJORIVEN CASING THICKNESS N TREMIE TYPE TO BE USED: ❑AUGERS pHOSE <br /> 0 VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL <br /> MPED: o NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a AIR SPARGE PUSH POINT BOLTED TRAFFIC BOX or a STOVE PIPE <br /> 'SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH `I5'� O <br /> CONDUCTOR CASING P POS N 4 (if YES.list specifications here): <br /> OTHER: <br /> GPCOMMENTS: <br /> '�(` NOTE: OFFSITE BORINGS R DIRE A CESS OR ENCROACHMENT PERMITS! <br /> I nereby certify that i nave prepared this application and Nat Ute work will be done in accordance with San Joaquin County Ordinances.State Laws,and Rules <br /> Intl Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: "f terrify that in the performance oftheo work <br /> for <br /> o which this permit is certifies the 1shall)notf certify that in the performance of the work for subject to WORKMAN'S COMPENSATION s permit s issued.I ws of shell OmPIOY Persons subject to <br /> 9 9 following: <br /> WORKMAN'S COMPENSATION Laws of Celifomia.- <br /> n �E APPPOCANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> ��5�� <br /> Title <br /> Signed x�_ / <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED 3 /////� <br /> DEPARTMENT USE ONLY i0 / 73 Area " <br /> Date Issued <br /> Application Accepted ByFinal Inspection BY Date <br /> Date <br /> Grout Inspection By Date <br /> Destruction Inspection By <br /> COMMENTS!CONDITIONS: <br /> FAC# <br /> ACCOUNTING ONLY: AID# <br /> DATE PERMITIS <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKMC//A��SH RECEIVED BY CE REOUE NUMBER INVOICE <br /> -6Z(O V !i V <br />