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WELL PERMIT APPLICATION ARM p <br /> UNIT <br /> REf <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES NOV 0 8 2000 <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 ENVIRONMENT HEALTH <br /> (209) 468-3449 PERMIT/SERVICES <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,Environ menton's Health Division. <br /> WELL Location Un [�11k 1(C 1.Y-• Cross Street W xarF City f zip 933G 4 Parcel# <br /> PROPERTY Owner C° c� °� Address city •t�Oh Zipgs3�O�O Phone# 209 's9 9'Ll0 8 <br /> C-57 Contractor��yLU&ow E_�C .AddressZi&5 W 10.,T_City Jrr-0" Zip9S2lJSLic#,amu 'hone#/ <br /> Consultant/Sub Contractor 15—kPv\ - 044+ Address l8(fl u• M, city�K,_Lic# Phone# 52-0o l6 <br /> GIS Coordinates:X ,Y ,Township 25 Range g E Section 3o <br /> WORK TO BE PERFORMED <br /> �OEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH, HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> SOIL BORING# 56 MW- 10 0 OVER-BORE <br /> 'WELL# Al -Z 9 0 PRESSURE GROUT <br /> *Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> it <br /> AMONITORING 0 HOLLOW STEM DIA.OF BOREHOLE Li1A MULTIPLE CASINGS? YES 0 NO WELL CASING DIA: 2 <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS Sols 90 TYPE OF CASING: O STEEL PVC 0 OTHER: <br /> 0 VAPOR fv1LID ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS *OSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: O Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 'SOIL BORING 0 HAND AUGER APPROX.BORING DEPTH 2�ID r XBOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER:_U OTHER CONDUCTOR CASING PROPOSED? NC> (if YES, list specifications here): <br /> . uEN�Tc. �n <br /> 21 <br /> yr.�s..tl <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,State Laws,+"ules <br /> and Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: "1 certify that in the performance of ork <br /> for which this permit is issued,I shall not employ persons subject to WORKERS'COMPENSATION Laws of California." Contractor's hirin=17 contracting signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, I shall employ persons suh, 17 <br /> WORKE OM NSATION Laws of California." <br /> THE PPLICANT MUST C L 48 WORKING HRS INA VANCE FOR ALL REQUIRED INSPECTIONS. C� <br /> Date ll I PI o <br /> Signed x Title e —� <br /> ' SEE SITE MAP UNIT IV WORK PLAN DATED: "a <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Issued O OG Area <br /> Grout Inspection By ( ��^�'✓� Dale Oa Final Inspection By Date l l O <br /> Destruction Inspection By Dale <br /> COMMENTS/CONDITIONS: <br /> 6ACCOUNTING ONLY: AID# <br /> S FEEINFO AMyOUNNTREMITTED CHECK# REC'D BY DATE PERMIT I SERVIICE REQUEST# INVOICE 1 l Eb rl ll IO 00 )r--):2 S Z <br /> C-57 LICENSED CONTRACTOR MUST SIGN LICENSE&WORKERS' COMPENSATION DECLARATION <br /> UNIT IV-6/23/99/sign bkpg/MI - <br />