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• • F1Y <br /> �hz�I ro n WELL PERMIT APPLICATION FORM <br /> ?o- r C 2 I SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION ("PHS-EHD") OCT 2 2 20011 <br /> _220 !3' 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> ' I r2,-2- <br /> (209) 468-3450 R1VIRO,ivi1-IuT HEALTH <br /> C- w - 2,� NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERPAT,'SERVICES <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 compliance with <br /> San Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br /> YAI, ) ty?pv ,n of+ Assessor's t� [� <br /> WELL Location 6 6 33 Pa C,4/' rc Cross Street <br /> City OG K"fo 11 zip 52 Parcel# n 9 7- //D- / <br /> PROPERTY Owner��woG� _ f�'D Address'! I -� - CrtY'S'S'DC'K'TD� Zipf 407Phone/'_t'44.1�� <br /> ^ ( SeLzSfoip SY73Lic#/7768/Phone#707-5�/2-3Z72 <br /> C-57 Contractor e.P.K� I/rlllrhClAddress PO P3 ox -7 �O City 2— <br /> /� <br /> Consultant/Sub Contractor L F9 Lf V�rze. �(c�e. Address /g00 PQ We I!Sf. City�/^e yvrlltCic# N Phone# <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED <br /> JEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE <br /> WELL# P� -2.2 a f� W- 22-5 PRESSURE GROUT <br /> •Other: <br /> COMMENTS: <br /> TYPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATION /2.2511-7.7-5- <br /> *MONITORING 0 HOLLOW STEM DW OF BOREHOLE MULTIPLE CA INGS7�'YES 0 NO WELL CASING DIA: 6 <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS 501 PO TYPE OF CASING: 0 STEEL #PVC 0 OTHER: <br /> 0 VAPOR #MUD ROTARY DEPTH OF GROUT SEAL O-CIO TREMIE TYPE TO BE USED: 0 AUGERS NOSE <br /> D AIR SPARGE O PUSH POINT GROUT SEAL PUMPED: IYes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING p HAND AUGER APPROX.BORING DEPTH /y,O *BOLTED TRAFFIC BOX or p ST11 <br /> OVE PIPE , <br /> B OTHER: CONDUCTOR CASING PROPOSED7-`_�(If YES,list specifications here): 12 Sfee l O-9, <br /> COMMENTS: <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: "I certify that in the performance of the work <br /> for which this permit is issued,1 shall not employ persons subject to WORKMAN'S COMPENSATION Laws of California." Contractors hiring or sub- <br /> contracting signature certifies the following: 'I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to <br /> WORKMAN'S COMPENSATION Laws of California." <br /> THE APPLICANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed x-J-10 /j 0 n­�-A _Title Date U <br /> SEE SITE MAP IN UNIT IV WORK PLAN. DATED "Pi► t 13A ~ - cvizw& <br /> DEPARTMENT USE ONLY 'Q Z3 �p Area- <br /> Application Accepted By Date Issued 17 <br /> Grout Inspection By Date Final Inspection B WLE® ,FAID Date_-97 / �� U <br /> v-1/ <br /> Destruction Inspection By Date !/ <br /> COMMENTS I CONDITIONS: <br /> FAC# <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#ICASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> 290 / A44V 2 Z 2 <br /> UNIT IV-5/99/MI <br />