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B-12-1999 10::OBAM FROM x _ P. 3 <br /> WELL PERMIT APPLICATION FORM UNIT'IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) r <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 ; %) <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES i YEAR FROM DATE ISSUED J <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 coir pliance w h <br /> San Joaquin County Developmel�litl©Ch ter 9 1115.:;,,�nd the�?i dards of San Joaquin County Public Health Services, Environmental Health Division, <br /> C.-_� ��0� G1�JlJ��C re��111V1 ti 7 r Assessors <br /> WELL Lecation SER � Cross Street ity �[o TD rel dip�SZU` Parcel# <br /> Hot=r'+..tA..f Z5 <br /> PROPERTY OwnerS"RS. txtr*A•.m�Addres &'5-733 �/<¢� Q City �.�st acs zip 401 9 Phone# Z <br /> C-57 Contractor_ i e..or j A „ Address.2Z7laZ FOL-IrY S'>=_City w sr- Zip r qr :VSLio# p5�1Z Phon 5/70 266-rJ <br /> �..��..��yy 7 Z <br /> Consuitan Sub Contractor-:17C C� p[ C1�y.4 Addres8'� Pt�r.0r ' AtAG,n.Ci �ty �7 Lic# Phone# - <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> NEW WELL I BORING(CPT, EOP RBE HYDROPUNCH, HAND-AUGER, OTHER`) III DESTRUCTION (choose type below) <br /> II SOIL BORING# i/ --i -5 VA--q VA-57j VA-to 0 OVER-BORE <br /> 'Other_ 0 WELL# j PRESSURE GROUT <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING U HOLLOW STEM DIA.OF BOREHOLE Z" MULTIPLE CASINGS?a YES I NO WELL CASING DIA;/I/m <br /> a EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS A TYPE OF CASENG �STEEL [] PVC �OTH>"R; <br /> a VAPOR p MUD ROTARY OEPTH OF GROUT SEAL IZ_r-zr--r TREMIE TYPE TO BE USED: Q AUGERS CHOSE <br /> 0 AIR SPARGE PUSH POINT(DP-r) GROUT SEAL PUMPED: a Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> 1 SOIL BORING HAND AUGER APPROX. BORING DEPTH i Z FEET- o BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER;_q OTHER CONDUCTOR CASING PROPpSED? t'J (if YES, list specifications here): <br /> COMMENTS:_ L aR__IaG,SWlr — 6t, �jlLli�c�►�jt �Ar'�f2t1 �� A.-i0 7HE7^/ Xj/,4A)VO-J2 <br /> Off' t��L�t_ 4Q S�nr 5I)[ 7o-Ag_ RarL�ns�s w�c_L t721 a 1 J<'n, <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 Ord4nances, 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,1 shalt 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 rhe work for-hich this permit is issued. I shall employ persons Subject to <br /> WORKERS'COMPENSA71ON Laws of Caliromia." <br /> THE:'APPLICANT <br /> MUS7_G; LT 48;W iZS-.1N.::ADVAN t,FOR ALL REQI].ERED..[NSP;EGTIONS: <br /> Signed- Fdi�-K �3 Title Ixx= sevcpGiss Date- /a/ <br /> SEE SITE MAP 44 UNIT IV WORK PLAN DATED: <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Issued Area <br /> Grout Inspection Ey Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: ST a-4 <br /> ACCOUNTING ONLY; Alox <br /> . <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK* REC'D BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> C-57 IGENSED CONTRA- TO MUSS S3GN I;ICENSE&�VC�RKE15'CAIPNSATIOI 'DECLAR i1 TION= <br /> Ui rT rV-6/23/99/sign bkpg/MI <br />