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41 <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) 4$8-3449 <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,Environ <br /> esstallsHealth Division, <br /> WELL Location 4162 ric AVaUE Gross Street City S?CCtcT�y _ZipGiS14-3 Parcel# <br /> c/p D4vl4 A74-ACfX-- <br /> PROPERTY Ownerl��Z✓!d� s b= _Address T�7 o I36k 431(0 City 5 15a7&-L( Zip yS-76V Phone# (zGrl) a-35�2J <br /> 5w X6 �gKCNo C9rrG� <br /> C-57 Contractor T MAI- Address 3233 F11 City ehet)-O ii' Zip/9;-7'/Z Lic*5Z 7`i Phone# _35-7Z7e- <br /> Consultant/ <br /> (cConsultant1 Sub Contractor 1w-W VPAo- AddressVM15 u• LIJJL'­t WACityL!'LC W%J Lic# (722 Phone# 5�G7 /GCE <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> Q1f4EW WELL/BORING(CPT,GEOPROSE, HYDROPUNCH, HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> p S IL BORING# 0 OVER-BORE , <br /> 4ELL# 0 PRESSURE GROUT <br /> "Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0NITORING W4OLt_OW STEM DIA.OF BOREHOLE S& MULTIPLE CASINGS?0 YES g-dO WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS-<40 'IO TYPE OF CASING: 0 STEEL g-OVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 7(? � TREMIE TYPE TO BE USED: R/AUGERS 0HOSE rr <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: fes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') } <br /> 0 SOIL BORING 0 HAND AUGER APPROX, BORING DEPTH GTO U15601-TED TRAFFIC BOX or 0 STOVE PIPE 4,= <br /> 0 OTHER:_0 OTHER CONDUCTOR CASING PROPOSED? 4A (if YES,list specifications here): <br /> ji <br /> COMMENTS: <br /> t <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: '7 certify that in the performance of the work <br /> for which this permit is issued, I shall not employ persons subject to WORKERS'COli11'PENSATiON Laws of California." Contractor's hiring or sub- <br /> contracting signature certifies the following: 7 certify that in the performance of the work for which this permit is issued, /shall employ persons subject to <br /> WORKERS'COMPENSATION Law of California." , <br /> �-CALL THE' IT I INSPECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED IN/tS_PECTIONS. <br /> Signed x Title/Company'IAAF CTEQLGIG�45-r- ADW!*L�� �i-fo ifL'��(�rtlrGt�iX 7tu1_ <br /> Print Name �N4sk, �r Sa.(...... .. .�... ...�,. _ . , .... . .-.Date G�4' 03-6 0. <br /> SEE SITE MAP IN UNIT IV_ WORK PLAN ,DATED <br /> ( DEPARTMENT USE ONLY r <br /> Application Accepted By Ck r -.Date Issued t)(I � y 7-0CDQ Area <br /> Grout Inspection By -a/f Date C Fina <br /> t Inspection By Date <br /> Destruction Inspection By, ate <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# ' <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC-D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> O 0 4 '-� <br /> 1/18/2000 <br />