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WELL PERMIT App�ICATIONIPORM COT W, <br /> �n SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> A�/0 ENVIRONMENTAL HEALTH DIVISION ("PHS-EHD'r) 21b <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 66u) • 6 <br /> (RMIT 468-3450 1 Y0 F kfUP <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 9-7115.3 and the Standards of San Joaquin County Public Health Services, <br /> ,-Environmental <br /> Asssessor s Health Division. <br /> WELL Location <br /> (,(J. ,I3>§�D cross SA"neer l L c- cliy Si"CY-k-#-o n Zip=�...1_Parcel# 09 z'`f(G —�i <br /> f �� r (.p.n+Cr Address <br /> 4�jNGo/n C errkr chY$� n Zip95ad"fPhone#209' 'y 9za <br /> PROPERTY Owner sebets+opol gsy73 /}768/ <br /> C-57 ContractorWee,�' P`'i D i n a Address P O Bok (7(0 —CityZip Phone#7o7-SYZ-3Z <br /> i2 { Y Lid! N A Phone# /0-652 <br /> Levine �i� s,;San pl,�a.//St � Cit mei Vi 112 <br /> Consultant)Sub ConlradorLFR kms_Addres <br /> WORK T I BE PER RMED �Q t ^ I�vO NGt) s <br /> p DESTRUCTION(choose type below) <br /> NEW WELL/BORING(CPT,GEOPROBE, DROPUNCH,HAND-AUGER,OTHER? n �g�-ZOJ,�W Z Ia O P PRESSURE GROUT <br /> SOIL BORING# G�w-1°( <br /> G�j <br /> Ls <br /> 'Other: <br /> COMMENTS: -45 <br /> TYPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIO ULTIPLE CA�NGS YES Q NO WELL CASING DIA:S 7� <br /> MONITORING Q HOLLOW STEM CA OF BOEHOLE <br /> �EXTRACTION �AIR HAMMER/DRNEN CASING THICKNESS SGH $O TYPE OF CASING: Q STEEL , PVC Q OTHER: <br /> VAPOR V MUD ROTARY DEPTH OF GROUT SEAL O— qO ' TREMIE TYPE TO BE USED: 0 AUGERS )HOSE <br /> AIR SPARGE /'Q PUSH POINT GROUT SEAL PUMPED:AYes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING Q HAND AUGER APPROX.BORING DEPTH I2- 0' BOLTED TRAFFIC BOX or�Sl S OVP�E <br /> p OTHER: PI r_y( <br /> CONDUCTOR CASING PROPOSED? _('itYES,list specifications here): <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS! <br /> andrRegucelartifytions la the San Joaquin County.IlHolmeowner or on and that the <br /> rcensed agents signature cerrt'fies thence lfoll wing:"l certify that n the performances <br /> e o!the work <br /> for which this permit is issued,1 shall not employ persons subject to WORKMAN'S COMPENSATION Laws of Califomla.' Contractor's hiring or sub- <br /> contracting signature certifies the following: '1 certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to <br /> WORKMAN'S COMPENSATION Laws of CalifOmia." <br /> THE APPLICANT MUST1 CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> J QAkA--r-� Q/1 l l�l'.I`, _Tole C2d _Date <br /> Signed x ` <br /> �O 0 <br /> SEE SITE MAP IN UNIT IV WORK PLAN. DATED <br /> DEPARTMENT USE ONLY <br /> Date Issued 7 <br /> Application Accepted By. Final Inspection By Date <br /> Grout Inspection By Date O v <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: - <br /> FAC# <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#!CASH RE IVED BY DA PERMIT/SERVICE REQUEST NUMBER INVOICI <br /> • ' Z <br /> UNIT IV-5/99/MI <br />