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0- I l L� U�4I1I r kur l _ P. <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> k 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 andlof install the work described. This application is made in compliance with <br /> San Joaquin County DevelopmenOtle.Ch z 3 nard <br /> ter 9 1115. d the�St ds of San Joaquin County Public Health Services. Environmental Health Division. <br /> r -' M L C� assessor's <br /> WELL Location �� (Zr �Oc t�- k ��: Cross Street t r ity ��l c 'to rel Zip <br /> 2SParcel# <br /> PROPERTY Owners` r � >9Q,-,�- t `ILS <br /> _�NfL2a_�-'BtJ��fl•so-o_Addres � --P,1..-- R City_�a;n;may Zip(aDt7gPhons# <br /> C-57Contractor1�t1?-.�rJ,cx -_Address 237tuZ Fc)+-E S-r. City_LAAYr,.JP A1ZiPfVS/SLir,#2D=Z7Phone <br /> !Iw <br /> Consultan Sub Contractor_:: ' 4t> ^Addressesarrt b.City C0+SC�DC�7 <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> III NEW WELL 1 BORING(CPT. EOP HYDROPUNCH, HAND-AUGER, OTHER') DESTRUCTION(choose type below) <br /> I SOIL <br /> #BORING# VA-40VA-7- 1&] VA--/ VA-97, VA-4> ©OVER-SORF <br /> 'Other: WELL . <br /> 1 PRESSURE GROUT <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING U HOLLOW STEM DIA.OF BOREHOLE ZV' MULTIPLE CASINGS?a YES J NO WELL CASING DIA: ` <br /> EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKN;SS�1 A _TYPE OF CASING: a STEEL 0 PVC II OTHER; <br /> O VAPOR a MUD ROTARY DEPTH OF GROUT SEAL I �ItT TREMIE TYPE TO BE USED: p AUGERS OHOSE <br /> 0 AIR SPARGE PUSH POINT(t>p-f) GROUT SEAL PUMPED: ®Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> I SOIL BORING HAND AUGER APPROX. BORING DEPTH 'Z Fie-CfT/� 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> Q OTHER: I7 OTHER CONDUCTOR CASING PROPOSED? • !( (if YES, list specifications here): <br /> COMMENTS: c�f�_t a G5 wt c_c_ P 21C_L Ae--L pby D 7N /'v rVD��nJ <br /> W]-rl kD c!F ,,I 4,T10 T., O L J,-t.t— C-A S:.,r.f 5 ='TAS ga2r LE w)c=am 8c i72;6-�rn I <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 l <br /> and Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: `7 certify that;n the performance of the work <br /> for which this permit is issued, i shall not employ persons subject to WORKERS'COMPENSATION Laws of Caiffornia." Contractor's hiring or Sub- <br /> contracting signature certifies the following: '7 certify that in the performance of rho work for which thispermit is issued, I shall employ persons subject to <br /> WORKERS'COMPENSA7iON Laws Of Califomia," <br /> TH:E.APP..LICANT MUST CALL 48 WORKIN0HRS IN:ADVANCE FO,R ALL.REPY Fit�D INSPECTIONS. <br /> ....::._ . 1. <br /> Signed Title R4PP­-­rtST Date <br /> SEE SITE MAP UNIT IV WORK PLAN DATED: lo /2- 2417 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By _ Date Issued Area60,ro <br /> Grout Inspection By Date Final Inspection 8y Date <br /> Destruction€nspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY; AIDri <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# RECD BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> 6714-5, �°� t'?g /l// 9 oyloz0 <br /> C-57:I ICENSED CONTRrCTOR:MUSS' SZCN IIGEN�E&WARS' C,4WLNSATICjIV DECLARITION <br /> UNIT IV-6/23/99 /sign bkpg/MI <br />