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.~ <br /> WELL PERMIT APPLICATION FOt <br /> OPY <br /> SAN JOAQUIN'COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION ("PHS-EHD") <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3450 " ` <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> null to construct andlor install the work described. This application Is made In compliance with <br /> ppucalion is hereby made to San Joaquin County for a pe on a Environmental <br /> an Joaquin County DevelopmentnTllk/,�C, <br /> Chapter 9�Q5.3 and the Stands ds of San Joaquin oaquin bounty Ph Serv���nvhAs� a� _Di /On'-�9 <br /> q�/ /A/ /'1/{7J lain` cross slice P cit SJ"OG •I"oYLzip <br /> TELL Location It O G k zip gsls Phone o 8 - ZoD <br /> l llCo/•., CQL1, vim _Address ZO - c/!aS-��/� <br /> ROPERTY Owner--�---- G <br /> 236 W ) �I�Cl Y1� CnySIO l }OV Zip 952o5Lidf Sitz oB Phone#� y <br /> .57 Contractor Sfi'�'� _Address * o <br /> Q aweIZ{'/.Cil m r i ic# N� Phone# S!o 652- <br /> onsutlanl I Sub Contractor LFk Levin ri k Address)`)(J P NA- SectionNJ— <br /> q Range <br /> NW y t J Township N <br /> :IS Coordinates:X�---� <br /> ]ORK TO BE PERFORMED p DESTRUCTION(choose type below) <br /> �HANQ-AUGER,OTHER') 0 OVER-BORE <br /> 'NEW WELL I BORING(CPT,GE L BORING <br /> HYDRrOP oCH, P ``ff U PRESSURE GROUT <br /> SOIL BORING# ` � rr/r� �_I�/� �-19�0 <br /> WELL# PT /I <br /> Dther. <br /> :OMMENTS: <br /> YPE OF WELL- 2- <br /> CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br /> �2 MULTIPLE CASINGS? YES. Q NO WELL CASING DIA: <br /> (MONITORING:'WELL YHOLLOW STEM DIA.OF BOREHOLE_.t�,O -SPE OF CASING 0 STEL xPVC 0 OTHER: <br /> I EXTRACTION `0 AIR HAMMEMRrVEN CASING THICKNESS S{7�— r yEMIE TYPE TO BE USED: 0 AUGERS HOSE <br /> p MUD ROTARY DEPTH OF GROUT SEAL <br /> -I.VAPOR GROUT SEAL PUMPED: Pas 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS E <br /> I AIR SPARGE 0 PUSH POINT Pas <br /> BOLTED TRAFFIC 80X or STOVE PIPE <br /> (SOIL BORING 0 HAND AUGER APPROX.BORING DEPTH ✓__�---- <br /> CONDUCTOR CASING PROPOSED? M O (fl YES,list specthcations here):_.___.__-- <br /> I OTHER: <br /> )OMMENTS: - <br /> CHMENT PERMITSI <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROA Slate Laws•end Rules <br /> hereby cerlifY that I have.prepared this application and that the work <br /> the work will be done In accordance with San J9aquln Conry ordinances, or sub <br /> Ind ebywRegBons of the San Joaquin County. Homeowner or licensed agent's signature cerlif�es the following: I CeNr I$hall employ persons subJelct to <br /> that In the performance <br /> /ormanca o!fhe wwk for whkh this permit is Issued, <br /> In which this permit the Is issued,I shall not employ t s Bre subject l0 WORKMAN'S COMPENSATION Laws o!Call(0mla'. Contractors fi 9 <br /> WRrjln9 signature ENScertifies the following:'1 certify EQWRED+N6�GTI0NSr-- — <br /> Iyp!{KMAMS COMPENSATION Laws Of Cal1(omia.' 8't'IRSiN-A�VAi�fcEF13R-A{"-E.-R <br /> -r�—•JI'YIeAPPI]CAi1T-MUST-CAtt�t <br /> �1 71t1e c�Mrn rJT��� <br /> sgned RK PLAN. DATED <br /> ---T-- <br /> SEE SITE MAP N UNIT IV WOz .03 <br /> DEPARTMENT USE ONLY Area (0 _ <br /> Date Issued Date <br /> Appkallon Accepted By Date__ —Final Inspection By <br /> Grout Inspection By Date <br /> DesWctbnlnspedlonBy <br /> COMMENTS I CONDITIONS: <br /> FACA <br /> ACCOUNTING ONLY: AIOIIDICE <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKMCASH RECEBY '� PERMITISE© EREQUEST NUMBER INS <br /> 7W pg�3b 3 3 <br /> UNIT IV- 5/99/MI <br />