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2- 10-2000 11 : 24AM FROM P- I <br /> WELL PERMIT APPLICATION FORM 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 /> Q r1 Assessor's <br /> WELL Location, vJ� �7 eSAG ttV<- Cross(('Street City•.•—City � Iu�1 Tb`^j Zip 9SZl Parcel# <br /> PROPERTY OwnerJt 6rM� _ Address -1 714 Fbu+l 'Rlr) �ja�lj� ;Qit�y\ 5,�,ft�Ck- "� zip y�sCZnpG�( Phone# ZC9 '" YSI '"��87 <br /> C-57 Contractor f; l t ei,5 IMS Address2Zg � K&ba�City . rLT ttin�te q4 I LIc#JOr� ---Phone#slfl �Z3Z -27& <br /> + <br /> 104 Cit %- c# �Z7tzfltzfl <br /> � — / r azs `),7MoJ� � 0tk UPhone# y $93 'S/GD <br /> Consul! Sub Contractor ci w� rir+a.t(� Address Y <br /> GIS Coordinates: X., Y., Township" _ Range Section <br /> WORK TO BE PERFORMED <br /> NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND'AUGER, OTHER") 0 DESTRUCTION (choose type below) <br /> SOIL BORING # Z D OVER-BORE <br /> 1] WELL # 0 PRESSURE GROUT <br /> "Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> p MONITORING p HOLLOW STEM DIA, OF BOREHOLE Z MULTIPLE CASINGS? D YES ONO WELL CASING OIA:T <br /> p EXTRACTION 11 AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING O STEEL U PVC n OTHER: <br /> [J VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: O AUGER5 OHOSE <br /> p AIR SPARGE PUSH POINT GROUT SEAL PUMPED: p Yes ) No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> SOIL BORING 0 HAND AUGER APPROX, BORING DEPTH .3h r _ p BOLTED TRAFFIC BOX or p STOVE PIPE <br /> p OTHER-..a OTHER CONDUCTOR CASING PROPOSED? ( If YES, list specifications here): <br /> COMMENTS 12wt 1`tV Se; r Cdit.L'� so t w i Ct.MOI+t,�1,.:� r <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> Thereby 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 of the work <br /> for which this permit is issued, I shalt 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, I shall employ persons subject to <br /> WORKERS' COMPENSATION Laws of California " <br /> CALL THE 'UNIT`IV IN PECTOR 48 WORKING HRS IN ADVAN. CE .FOR-ALL REQUIRED INSPECTIONS, <br /> Signedx <br /> e 'T, <br /> c � TitlelCompany "� e • ' '^ ' '�' — Cit�:fv✓ ctd'� �j Z �-� �"/r- - <br /> Print Name �ce7' -; rnu '1U I Date L f 8 <br /> IOU, II SEE ZITE:;MAP IN UNf 11/ ;V(i'C�'RPC! PLA DATE[3 A <br /> DEPARTMENT USE ONLY <br /> Date Issued Z /r <br /> Application Accepted By � .. D <br /> Grout Inspection BDate454Joe) Finallnspection By <br /> Destruction Inspection By Date <br /> COMMENTS / CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT / SERVICE REQUEST # INVOICE <br /> 3Sd � . 00 21 1.3 z 00 0 ( a � o <br />