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12-23-1999 3 S7PM FROM P 2 <br /> r r <br /> WELL PERMIT APPLICATION FORM <br /> UNIT 1V <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION ("PHS-EHD") <br /> 304 E Weber, Third Floor, Stockton, CA , 95242 <br /> (eas) 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 cornstruct andlor install the worts described This application i5 made in corriplianCe with <br /> Gas. Environmental <br /> San Joaquin County Development Title Chapter 9-1115 3 and the Standards of San Joaquin County Public Health ServiAS Health Division <br /> taTtH INS C+t �-'Op I Zp��_Parcel'>±f <br /> WELL Locatlon 20 W- KETTI E�A� •Cross Street IIAy <br /> PROPERTY Owner GREC702ti' TC�-IERKOYAKAddress ISS <br /> C.e.NYON Cay <br /> C 57 Contractor�`Z I� aE► r21 V--1_�f3 Address 9 p w <br /> City bg t� Zip945S.3 L+c#jjs_l Phone�,�925�313-WOO <br /> Cansuitantl Sub Contractor CA wt 91k%A f=lJ LIMO Z �JkLAdaresS 2-10 <br /> :"1511M ItAS ST CAy_S9tA0tAp. Lica 1J A-_PhoneA <br /> GIS Coordinates X Y <br /> Township Range Section <br /> J <br /> WORSE To BE PERFORMED <br /> ❑DESTRUCTION(choose type oelow) <br /> WW VVELL I BORING(CPT GEOPROSE HYOROPUNCH HANG-AL1G€R OTHER-) fl OVER-BORE <br /> WS01L BORING# - r&4 SB-4 a PRESSURE GROUT <br /> Q WELL# <br /> Other <br /> C%�z+tMENTS <br /> E OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br /> WELL CASING CIA <br /> ONITORING 0OLLOW STEM DIA OF BOREHOLE $�MULTIPLE CASINGS?0 YES Q NO <br /> TYPE OF CASING a STEEL Q vVC 4 OTHER <br /> a EXTRACTION a AIR HAMMEWDRIVEN CASING THICKNESS HOSE <br /> r�VAPOR 0 MUD ROTARY DEPTH OF GROLrr SEAL TREMIE TYPE TO BE USED 0 AUGERS Q <br /> AIR SPARGE G PUSH POINT GROUT SEAL PUMPED G Yes I3 No (NOTE- MAXIMUM FREE-FALL DEPTH IS 301 <br /> SOIL PARING HAND AUGER APPR07C BORING DEPTH 't'S ' M O BOLTED TRAFFIC BOX or a STOVI< PIPE <br /> J OTHER <br /> CONDUCTOR CASING PROPOSED (+f YES list specsficat+ons here) <br /> COMMENTS <br /> NOTE OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITSI <br /> �en'by ctlrUFf that 1 have prepared this app17cat+an and that the worx will be done in 3CZordance with San Joaquin County Ordinances State Laws and Rules <br /> aril? Regulations of t*e San Joaquin County Homeowner or licensed agent's signature certifies the following "l certrfY that"'rho Perfdrrnance of the work <br /> ATIOM <br /> for which this permit is issued,l shall notQ MP'oY Persthat inO the pertormar+ce WORKMANS subject to A9 s✓o rOrDwM'th this permit rs issued ws of CBrshell employ opersons sialect to ntractor'&hiring or sub <br /> contracting signature certifies Vie following certify <br /> AtORKMAN S ComPENSA770N Laws of Califomra - <br /> THE Pt (CANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS J <br /> Title C1fJ ArDate_ <br /> V IF <br /> Signed <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED sc-P�� B*✓R 30 999 <br /> DEPARTMENT USE ONLY py L0 <br /> / � Date Issued /��''�/! / Area r <br /> Appl+catLon Accepted By� - Date <br /> Grout Inspection By <br /> Gate Final Inspection By <br /> Destruction Inspection By Date � <br /> OMMENTS!Inspection <br /> y �� �� <br /> FAC: <br /> ACCOUNTING ONLY AID* t <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKPWCASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE <br /> 3S of �" IV 3 <br />