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11 -22-1999 8 40AM FROM P 3 <br />' 10-04-1999 10 32AM FROM P 1 <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> r <br /> SAN JOAQUiN COUNTY PUBLIC HEALTH SERVICES- <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) - <br />' 304 E Weber, Third Floor, Stockton, GA , 95202 <br /> (209) 468-3449 <br /> NON-REFUNCIABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> I <br /> ppl Catton is hereby made to 5an Joaquin County for a permit to construct andjor Install the work described Tnzrs application is made in compliance wtt l <br /> an Joagvrn County Dovolopme Ent Title Chaptar 8-1115 3 and the Standards of San Joaquin County Public Health Services Envrronmentat Health doviMipn <br /> C� Lmc lil s� h k S� k� Assessors <br /> WELL Location 401 .S D to Cross Street C�t/rG .S'�` city o c!!_-__ 0 H zrpF'arcelre_ i r(7 - Cl 1 y -c <br /> I <br /> ROPERTY Owner keV In �ASS o Address 114 5 Irl C.�I u✓t cy wa/Coy Si',41-lri mo 4-520(a phone* Zo-1 -4roie- 51°►L <br /> an g5r7 }Ior! Mu.43AC Z q45-5_342,51 W5 <br /> I <br /> C 57 Contractor � .9 r1 Addreas �_- City Ztp Lie# Phone# <br /> IL-0 <br /> Ecus Pa 3v�t 99z�� h.�,.yo °Iy�7 <br /> Ronsultant/Sub Contfoctor Address __ City�Llco Phonatf <br /> IS Coordinates X Y _ Township Range Section <br /> WORK TO BE PERFORMED <br /> EW WELL t BORING(CPT,GEOPROgE,HYDROPUNCH HAND-AUGER, OTHER') Q DESTRUCTION(choose type below) <br /> U SOIL BORING# Q OVER-BORE <br /> ATWELL# 1J11t1 _. W -7�-1�5.4+t -3 0 PRESSURE GROu r <br /> thcr <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECiFtCATIONS <br /> _ <br /> NITORING ,S'HOLLOW STEM DTA OF BOREHOLE r MULTIPLE CASINGS-1 11 YES Q NO VVELL CASING OIA jr't <br /> FEACTION 11 AIR HAMMERrDRIVEN CASING THICKNESS____ . TYPE OF CASING U STEEL ,a F VC U OTHER <br /> VAPOR Q MVC)ROTARY DEPTH OF GROUT SEAL _ , _ TREMIE TYPE TO BE USED []AUGERS []HOSE <br /> AIR SPARGE Q PUSH POINT GROUT SEAL PUMPED Q Yes Q No (NOTE- MAXIMUM FREE-FALL DEPTH 15 36') <br /> $$OIL SORING I7 HAND AUGER APPROX GORING DEPTH - 1-5 r 13 BOLTED TRAFFIC BOX or O STOVE PIoE <br /> OTHER 0 OTHER CONDUCTOR CASING PROPOSE[)?_(if YES Inst speCifrcation5 here) <br />�OVIMENTS <br /> NOTE. OFFSITE BpRINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> t—herebycertify that I have prepared this application and that the work wilt be done In accordance with San Joaquin County Ordinances State taws and RU es <br /> nd Regulations of the San Joaquin County Homeowner or licensed agent s signature certifies the following "1 certify that in the performance of the worA <br /> for which this permit is issued 1 sholl not employ persons subject to WORKERS C0mpEmSu4TION Laws of Cabhomra" Contractors hiring oe sus <br /> contracting signature certifies the foitowing 'I Certify'hat In the performance of the work for which this permit is issuod I shall employ persons subject to <br /> WORKERS COMP€NSATlON Laws of COLMmro <br /> THE APPLICANT" MUST CALL 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS <br /> Signedx Tdla C•onst/44grJ- Date <br /> SEE SITE MAP14 UNIT IV WORK PLAN DATED 111, 1111 <br /> DEPARTMENT USF-pbtLY <br /> tfout <br /> ppltca'Ion Accepted Sy Date Issued //"L �Inspection 6y_._ Date I"incl Inspection By nate <br /> Destruction Inspeebon By bate <br />'COly MIEI NTS/CONDI'T'IONS ow <br /> OUNTiNG ONLY AID# <br /> PE CODES FET:INFO AMOUNT REMITTED HECK REG D aY DATE PERMIT!SERVICE FtEQtIE$7& INVOICE <br />' C-57 LICENSED CONTRACTOR MUST SIGN LY ENSE &WORKERS' COMPETSAnON DTCLARA-n0N <br /> t1'.fiT YV- &12ti/4q 1s.nn I+trnn/tAT <br />