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1/ ..i. <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct 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 Divis:cn <br /> Assessor's <br /> WELL Location 2" W. 1.1a2 r A 11v1 Cross Streety llin Un 0.. City .51* A AC r Zio Parcel# f 13 3ZO d1 <br /> PROPERTY Ownerst"s tl-a�d..;�s I.nc. Address ta0 eoX 445 City Esc%ka" Zip`IS320Phonem L09 f{3E{`<yU(� <br /> C-57 Contractor t'vet. ddress 3g9 SVtarti QiRte City llty n 4iplQ�LiC•i1: Phone# <br /> �Q �e <br /> Consultant/Sub Contractor AT?. Qssae.e�a.s Lv% Addresst%%1 I.ur•Qelw�,(..eug CiryW{edn6�o Lic# Phone# aql <br /> GIS Coordinates:X ,Y ,Township 1 14 Range G Section �6 <br /> WORK TO BE PERFORMED <br /> NEW WELL/BORING(CPT,cL,turtjSlist-. HYDROPUNCH,HAND-AUGER,OTHER-) O DESTRUCTION(choose type telow) <br /> 0 SOIL BORING# 5611 a OVER-BORE <br /> p WELL# 0 PRESSURE GROUT <br /> *Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING O HOLLOW STEM DIA.OF BOREHOLE 7_ MULTIPLE CASINGS?DYES 0 NO WELL CASING DIA:- <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS 3 rA- TYPE OF CASING: O STEEL O PVC O OTHER: <br /> O VAPOR O MUD ROTARY DEPTH OF GROUT SEAL IZ-7-G C L TREMIE TYPE TO BE USED: 0 AUGERS OHOSE <br /> G AIR SPARGE ''PUSH POINT GROUT SEAL PUMPED: p Yes VNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> `SOIL BORING O HAND AUGER APPROX. BORING DEPTH 12 .Fa 2L �}- 0 BOLTED TRAFFIC BOX or p STOVE PIPE <br /> O OTHER:_O OTHER CONDUCTOR CASING PROPOSED? (if YES, list specifications here): <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, I shall 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 the work for which this permit is issued, /shall employ persons subject to <br /> WORKERS'COMPENSATION Laws of California." <br /> /CALL THE UNIT IV INSPECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed x Title/Company Tc- S So c-oat s. �ne c - <br /> _ 11 <br /> Print Namnn 0 JIexkva� 1AomSe,"-1 Date IO` IF100 _ <br /> SEE-SITE MAP IN UNIT IV.WORK PLAN DATED <br /> () DEPARTMENT USE ONLY �f <br /> Application Accepted By �•'t• Date Issued "� r Area <br /> Grout Inspection By T JyyC G -Bate 11 Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FArt <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 35-01 g9. 01 TO Z 1 L&A it1 o� -3 . . <br /> 1/18/2000 <br />