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0F PY <br /> WELL PERMIT APPLICATION FORM UNIT I <br /> '::I El V ED <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICE C <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) MAR 16 2000 <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 ENVIRONNIEINTAL_ HEALTH <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT i SERVICES <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 /> Assessor's <br /> WELL Location 3131 E Fee-mgn7T s�, . Cross Street 9&AJwAL1City 51ack,faiJ Zip LDS Parcel# ly3-,�2D-1 y <br /> PROPERTY Ownerremk- hbti It7/V Address IJ • 8��4,�/t�xmy City. 57ak Zip 15-ZOS Phone#_�((0Jr' —S(G.g5 <br /> d WY <br /> C-57 Contractor��E� ►�"► <br /> I�- d,+ �ddress 400SNL l�l SL'Y1 14(--1-City mik, Zip S'4�ic# 604�t7Phone# 4�0'/00(.0 <br /> Consultant/Sub Contractor Address City Lic# Phone# <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> ANEW WEtL/BORING(CPT, WPR <br /> HYDROPUNCH, HAND-AUGER,OTHER-) DESTRUCTION(choose type below) <br /> ASING# S 0 OVER-BORE <br /> WELL# 0 PRESSURE GROUT <br /> 'Other: Ie�/✓IM I(�, A�'d i�( <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE,,, 7s,;IMULTIPLE CASINGS?0 YES ; WELL WELL CASING DIA: A <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: O STEEL 0 PVC 0 OTHER: Alm <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL ftSIAjl':�e TREMIE TYPE TO BE USED: O AUGERS OHOSE <br /> 0 AIR SPARGE PUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH T IDS •0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <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 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 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 employ persons subject to <br /> WORKERS'COMPENSATION Laws of California." <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HRS IN ADVANCE`_oFOR ALL REQUIRED INSPECTIONS. <br /> Signed IIOn � <br /> NS. <br /> Signed /tnst�fd"�/ /` Title/Company s� .��Y .ced&&Jiliaejk.,-�✓ L' <br /> Print Name /0A I G/c H Date V <br /> S E SITE MAP IN UNIT IV ,WORK PLAN A ED O 3h 5=- 00. <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Issued Area <br /> Grout Inspection By Date Final Inspection By Date <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 /> yyol 2.��1 3SR422(� <br /> 1118/2000 <br />