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i <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 Floor, Stockton, CA , 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct andlor install the work described This application is made in compliance with <br /> San Joaquin County evelopmen T tie ha er 9-1115 3 and the Standards of San Joaquin County Public Health Services Environmental Health Division <br /> I ( ` Assessor's <br /> WE If ocation t`� Cross tr t a[Xi r'^\ek City Slack Von zip'15201 Parcel# �3`l-7'!O-O`f-7 <br /> 148 a hr. <br /> PROPERTY Owner ' Address S.ati 250 �C�it_� p one# <br /> C-57Contractor u�uo � \k Address PO )01( - Clty�—ZIpgq�1Lic#-7)CM77 Phone# <br /> Z ocity" ".@Lic#22oZ93 Phone#`h.-63l"(3a-b <br /> Consultant/Sub Contractor 1�G, Address o <br /> GIS Coordinates X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> NEW WELL 1 BORING(CPT,GEOPROBE HYDROPUNCH, NAND-AUGER OTHER') O DESTRUCTION(choose type below) <br /> 0 OVERBORE <br /> 0 SOIL BORING# <br /> O PRESSURE GROUT <br /> WELL# <br /> 'Other <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS i• <br /> OREHOLE E3" MULTIPLE CASINGS?0 YES �NO WELL CASING DIA <br /> MONITORING HOLLOW STEM DIA OF BESS <br /> O THICKNsc!^ qd TYPE OF CASING 0 STEEL XPVC [)OTHER_ <br /> EXTRACTION O O LOW ST HAMMER/DRIVEN CASING GROUT SEAL SCG 6,eAow TREMIE TYPE TO BE USED AUGERS OHOSE <br /> WOR 0 MUD ROTARY DEPTH T <br /> SPARGE 0 PUSH POINT GROUT SEAL PUMPED )tYes 13 No (NOTE MAXIMUM FREE-FALL DEPTH IS 30') <br /> O SOIL BORING 0 HAND AUGER APPROX BORING DEPTH SG-e- L,c jam OLTED TRAFFIC BOX or []STOVE PIPE <br /> O OTHER 0 OTHER CONDUCTOR CASING PROPOSED? (if YES,list specifications here) <br /> COMMENTS <br /> w�l! -11 12 TD = 12o4 rtL�-5-e,4¢o 106&l <br /> (.Uc.lk U-111 T = 70 U row#- S�.t A-0 <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 11 certify that in the performance of the work <br /> for which this permit Is issued, l shall not employ persons subject to WORKERS'COMPENSATION Laws of California" Contractors hiring or sub- <br /> contracting signature certifies the following "!certify that in the performance of the work for which this permit is issued t shall employ persons subject to <br /> WORKERS COMPENSATiG+J Jaws or Caufornia <br /> A T MUST CALL (48 }WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS <br /> Signed x <br /> d 1 D 4 „ C� {S _ 2 <br /> rZa TitleDate <br /> 00 <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED No.e.,n6eir <br /> DEPARTMENT USE ONLY <br /> Application Accepted By <br /> Date Issued 3" v Area — <br /> Grout Inspection By <br /> Date Final Inspection By Date_. <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS U 1 <br /> W -t a C g,1. '1 <br /> Iff <br /> NG ONLY AID# <br /> FEE INFOAMOUNT REMITTED CHECK# RECD BY DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> 1 b Soo O o �-�- ft-b <br /> C-57 LICENSED CONTRACTOR MUST SIGN LICENSE&WORKERS' COMPENSATION DECLARATION <br /> UNIT IV-6/23/99 /sign bkpg/MI <br />