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WELL PERMIT APPLICATION FjTRM UNIT IV <br /> NOV 1 6 2001 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION ("PHS-EHD") <br /> ENVIRONMENT HEALTH 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> PERMIT/SERVICES (209) 468-3450 <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 sHealth Division. <br /> WELL Location 1810E H4zelt0h Ave, Cross Street l3 <br /> St ej' City StOOltgh Zip95205 Parcel# /�S"180'OL <br /> 109 <br /> PROPERTY Owner Sqq J'O44kf4 Gauq�V Address 1121 E, SCP1t5 AVB, City_ tOCK tOq Zip95�20s Phone# 6 99 25 <br /> qq aa C 161 <br /> C-57Contractor Mitchell Drilling Address 10616 Mi1q 110 Way CiIyCCT4 CV 4- Zip Sb LiW W( S}l Phone# bit- 3 83 <br /> T050'%, I1,4wla9ti P,O. ¢ox 669 ( 91 -L <br /> Consultant/SubContractor�aW4 rTNViYONMf!. AddressRghc110Murreta- City 956 Lic#5B5 6 Phone# 354 - 32C0150 <br /> GIS Coordinates:% <br /> 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 /> 0 SOIL BORING# 0 OVER-BORE <br /> 0 WELL# MW-3# 0 PRESSURE GROUT <br /> 'Other; <br /> COMMENTS: OTIC On-site MOh110)rfWt I <br /> TYPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING I HOLLOW STEM DIA.OF BOREHOLE 'INCH MULTIPLE CASINGS?0 YES I NO WELL CASING DIA:1-fN <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS ScN 0 TYPE OF CASING: 0 STEEL I PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 31-FE 6 r TREMIE TYPE TO BE USED: I AUGERS OHOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: I Yes O No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH SS- Ft E r I BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> p OTHER: CONDUCTOR CASING PROPOSED? NO (if YES,list specifications 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, Slate 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,1 shall not employ persons subject to WORKMAN'S 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 /> WORKMAN'S COMPENSATION Laws of Califomi " <br /> HE PLIC 8 RS IN ADVANCE FOR AL REQUIRED INSPECTIO S. <br /> 'N A/Z." Title r � Date <br /> 1/ 41 Z <br /> Signed x <br /> SEE SITE MAP IN UNI IV WORK PLAN. DATED Ta 11 16 , 1001 <br /> DEPARTMENT USE ONLY <br /> �( Date Issued,�[�T _____-----Area <br /> Application Accepted By Date <br /> Grout Inspection By J4 <br /> LYiO I I Date I 13 I Final inspection By <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> FAC# <br /> ACCOUNTING ONLY: AID# <br /> CHECK#ICASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> PE CODES FEE INFO AMOUNT REMITTED <br /> 301 'TJ " 671 - 11�Sb t�K �l�z fie/ L� 2 rS I Si, <br /> UNIT IV-6/1/99/sign bkpg/MI <br />