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FILE COPY • � ������ <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third <br /> (2or, Stockton, CA., 95202 <br /> 09) <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct andfS install the work described. This application is Assessors Health <br /> compliance with <br /> San Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County PublicoJ <^21thZServices, <br /> Z vuAs Ce sons lts Fivision.k�-� <br /> q3-2 L. �,vZ.' Cross Street l.Lc+�F,^r_ ^"city ,� <br /> WELL Location 5V-1 ,► Zipf�7' 7-' 3r/�i <br /> I SIKrI City h c2 Phone# 93 8 <br /> /� j _ Sb,-k� ,� Address 4Z5 N CI�' r c1,'. <br /> PROPERTY owner ; 1 v6. Zip rIS7`�2Lic#7r751J Phone# QI6-�S-IIGri <br /> L✓cl l llw. Address �� �� ori, ^i 1�CitY <br /> C•57 Contractor C `� / <br /> _ 1'Jc_Kk� <br /> >,'. i Cr.,II, 75'77 Phone# 41f;-63i" I�tT/J <br /> r. �j I w _Addresses <br /> Consultant/Sub Contractor ' Range_ —Section <br /> GIS Coordinates:X__�'Y— <br /> Township <br /> WORK TO BE PERFORMED 0 DESTRUCTION(choose type below) <br /> OVER-BORE <br /> ` NEW WELL/BORING(CPT. SOILGEOPROBE. <br /> BORING <br /> HYDROPUNCH.HAND-AUGER.OTHE 0 PRESSURE GROUT <br /> G SOIL BORING#r � � U - 23 <br /> WELL# U <br /> 'Other: <br /> COMMENTS: <br /> DIA.OF BOREHOLE_MULTIPLE CASINGS?a YES I�T10 WELL CASING DIA: <br /> TYPE OF WELL INSTALS CONSTRUCTION SPECIFICATIONS <br /> MONITORING r�g'HOLLOW STEM �e r j,) TYPE OF CASING: 0 STEEL ( PVC Q OTHER: <br /> a EXTRACTION a AIR HAMMERIDRIVEN CASING THICKNESS r TREMIE TYPE TO BE USED: GAUGERS VOSE <br /> 0 VAPOR g MUD ROTARY DEPTH OF GROUT SEAL 54�No OTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> PUSH POINT GROUT SEAL PUMPED: Yes D <br /> 0 AIR SPARGE 0 r Q 12C{L'BOLTED TRAFFIC BOX or B STOVE PIPE <br /> HAND AUGER APPROX.BORING DEPTH 7� <br /> �SOIL BORING <> CONDUCTOR CASING PROPOSED? (it YES,list specifications here):__ <br /> 0 OTHER. p OTHER— lye r.7eJ-' � 33 _,,YI e� <br /> w Strom{ '3� <br /> COMMENTS:10 <br /> � StU LI�� Sri <br /> NOTE: OFF <br /> ITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby certify the,.have prepared this application and that the work will be doge in accordance with San Jgoaquin County Ordinances,State Laws,and Rules <br /> 1 shall not employ persons subject to WORKERS'COMPENSATION Laws of California." Contractor's hiring or sub- <br /> and Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following, I certify that in the performance oft the work <br /> for which this permit is issued, <br /> contracting signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, I shall employ persons subject o <br /> WORKERS'COMPENSATION Laws of California" G <br /> t <br /> ML NT MUSG HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> T CALL 48 WORKIN7_ Lert <br /> I �P 1.4Date <br /> TitleSigned xv <br /> SEE SITE MAP IN UNIT IV WORM NTWORKDATED:DEPART <br /> Date Issued ^ I�'"" ( '� Area__— <br /> Dot <br /> lot L, Date_ <br /> Application Accepted By /J Final Inspection By <br /> Date_ <br /> Grout Inspection By Date <br /> Destruction Inspection By <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# # INVOICE <br /> RECD BY DATE PERMIT 1 <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# lit( .` 10 Il U0 (]�QUEST <br /> a 8` 313 ��— l CLARATION <br /> 3 I ' sATIo <br /> TCRTTSED CONTRACTOR MUST SIGN jjCENSE&WORKERS CO <br />