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WELL PERMIT APPLICATION F1!.1:'.:M UNIT lv <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, Envi Ass onmental Health Divis.3:7 <br /> WELL Location Z53qN1.9ln/ �`���� Cross Street (NGT ALcX City.Gf/W7Z-1Zo4 Zip Parcel# Z 19-.36--36 <br /> Address �� �Si City iL1A�L!'TacA Z Phone# 0! -Y��� <br /> PROPERTY Owner/7,,r /f�.AN7 -- <br /> C-57 Contractor _ - - �t-rcG�nr�i Address 959-5,z, AA f n-VA4 A City Zip Str< Lic#(c S Phone#�O,; <br /> Consultant/Sub Contractor Address City Lic# Phone# <br /> GIS Coordinates:X <br /> Y Townships S Range X7Z�- Section <br /> WORK TO BE PERFORMED <br /> )ZNEW WELL/BORING(CPT, GEOPROBE,HYDROPUNCH, HAND-AUGER,OTHER') 0 DESTRUCTION (choose type t:e!o.J <br /> 0 SOIL BORING# 0 OVER-BORE <br /> 0 WELL# / 0 PRESSURE GROUT <br /> 'Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> )Q�A0NITORING HOLLOW STEM DIA. OF BOREHOLE 6 'fib MULTIPLE CASINGS?0 YES ;00 WELL CASING DIA:Z-0 <br /> EXTRACTION AIR HAMMER/DRIVEN THICKNESS 5ft-! '/o TYPE OF CASING: 0 STEEL QVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL '/ar;-,C.TREMIE TYPE TO BE USED: 0 AUGERS VFIOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> r <br /> 0 SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH Z<.U —OLTED TRAFFIC BOX or 0 STOVE PIP-E <br /> 0 OTHER:__0 OTHER CONDUCTOR CASING PROPOSED? (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, State Laws,and R.i!es <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 shall 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 empioy persons subject to <br /> WORKERS'COMPENSATION Laws of California." <br /> C LL THE UN T IV I PECTOR 48 WORKING HRS IN AD ;NCE FOR ALL REQUI ED INSPECTIONS. <br /> 17 <br /> Signed x Title/Company L7�- j U/r^r <br /> Print Name • �e8)cDate /Z ' <br /> y <br /> SEE SITE MAP IN UNIT lV WORK PLAN DATED: <br /> EPAR�TMENT SE ONLY /� <br /> Application Accepted By "V Date Issued T6vD Area____- — <br /> Grout Inspection By to f inal Inspection By Date_-- <br /> Destruction Inspection Da Gtyl <br /> ------ <br /> COMMENTS/CONDITIO S: <br /> d <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REVD BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 1/18/2000 <br />