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f L f COP 'S • • <br /> WELL PERMIT APPLICATION FORM _ <br /> UNIT IV <br /> SAN JOQUIN COUNTY <br /> RONMENTAL HEALBI <br /> HDIVIS ON PHS-EHD)LIC HEALTH S <br /> ENVIStoc <br /> 304 E- Weber, Third 9) 468 3449kton, CA., 9520 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> permit to construct and/or install the work described. This application is made in compliance with <br /> Assessor,32 '24'✓ 'i 7-U <br /> Application is hereby made to San Joaquin County <br /> for a p �-� Zip �i52iit Parcel#_�— <br /> San Joaquin County Development Title,ChapterAA9-1115.3 and the Standards of San Joaquin County�Pub}li�c Health Services, Environmental Health Division. - <br /> F �- Cross Street C�I` nom"=City�S — <br /> y 3� C• ("I i v�2( •' _ Zip QCL$ I Phone# <br /> WELL Location -7 Address 1`1 L' c.t.: 7t7'iKPhone#�/�" ! <br /> -rc..�+:..,. C >zia.�r. Zip4�7`r2Lic# <br /> PROPERTY Owner�,)rla•� 1.•. .3L3� C. r2 c: C�r'o-li--City I <br /> � Ll_rllu� Address Zn"O$I- (lr-Cal ' <br /> IYSc 55 I"( Phone#_�� <br /> C•57 contrector_��t,.., �.� '� I%crt city Cr.r�s��•3• Lic# ,. <br /> Address <br /> Range__ Section�— <br /> Consultant ISub Contractor C Township�� <br /> GIS Coordinates:X_�Y <br /> WORK TO BE PERFORMED Q DESTRUCTION(choose type below) <br /> Q OVER-BORE <br /> 1 Q PRESSURE GROUT <br /> A NEW WELL f BORING(CPT. SCILBOR NG#OROPUNSHl.HZ ND AU S OT;E � S 7 i+ <br /> WELL#J...Z -2� <br /> -Other: <br /> COMMENTS: CONSTRUCTION SPECIFICATIONS NO WELL CASING DIA.�� <br /> INSTALLATION TYPE DIA.OF BOREHOLE'3 .1114 10" MULTIPLE F CASING: 0 STB PVC Q OTHER. <br /> TYPE OF: �— yC TYPE OF CASING: Q STEEL �. <br /> HOLLOW STEM CASING THICKNESS S . <br /> ',Q(MONITORING '�AIR HAMMER/DRIVEN lr ,),� TREMIE TYPE TO BE USED: Q AUGERS ;gHOSE <br /> Q EXTRACTION Q MUD ROTARY DEPTH OF GROUT SEALy— NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> XVAPOR GROUT SEAL PUMPED: lg.Yes Q <br /> No STOVE PIPE <br /> Q PUSH POINT ,,,,y OLTED TRAFFIC BOX or Q <br /> -XAIR SPARGE APPROX.BORING DEPTH See 6 1�— <br /> Q HAND AUGER if YES,list specifications here):_ <br /> Q SOIL BORING CONDUCTOR CASING PROPOSED? ( 'r <br /> Q OTHER:_-�Q OTHER— 2 '4'I..n u-B I kb -6 <br /> COMMENTS: Z. n^: ,•� I Iti 7S 4 12ri` ('� 2- <br /> 7 <br /> \ .'2 i,vo.• 1lnn 2'-I - <br /> I . , I l l� �k. CGS <br /> CCESS OR ENCROACHMENT PERMIT <br /> INGS REQ IRE A State Laws,and Rule' <br /> NOTE: OFFSITE BO <br /> re ared this app nature certifies the following: "1 certify that in the performance of the work <br /> lication and that the work will be done in accordance with San Joaquin County Or loan , <br /> I hereby certify that 1 have P P Joaquin County. Homeowner or licensed agent's sig I shall employ Persons subject to <br /> and Regulations of the San Joaq 1 shall not employ persons subject to SIC Laws of California.' Contractors hiring or sub. <br /> (orwhich this permit Is issued, that in the performance of the work for which this permit is issued, <br /> contracting signature certifies the following: "I certify <br /> WORKERS'COMPENSATION Laws of California." ADVANCE <br /> j0 r r /LYS <br /> T EQ <br /> LICANT MUST CALL 48 WORKING HRS IN ADV�A�GkFG2A`a R L U Date <br /> D INSPECTIONS. <br /> �" � Title l7 7 <br /> / DATED: <br /> Signed z 1 WORK PLAN <br /> SEE SITE MAP IN UNIT IV V ��I 9 <br /> DEPARTMENT USE ONLY Area <br /> Date Issued Date <br /> Final Inspection By <br /> Application Accepted By Date---- � <br /> Grout Inspection By Date <br /> Destruction Inspection Bly <br /> COMMENTS I CONDITIONS: <br /> # PERMIT I SE QUEST# INVOICE <br /> ACCOUNTING ONLY: AIDREC'D BY DATE <br /> PE CODES FEE INFO Am LINT CHECK# <br /> NT REMITTED , lull-Ileo °a. 3 CLARATIC <br /> SAT .ION <br /> 35� ffll, <br /> ST SIGN LICENSE &WORKE'RS' CO <br /> LICENSED CONTRACTOR NIU <br />