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i <br /> WELL PERMIT APPLICATION FuRM UNIT IV- <br /> �.. OAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ,f1t:CE1IRONMENTAL HEALTH DIVISION ("PHS-EHD") <br /> NOV ���� 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3450 <br /> ENVIRONMENTAL HEALTf�OWREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> PERMIT/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 Tale,Chapter 9-1115.3 and the Standa s of San Joaquin.County Public Health Services, Environmental Health Division. <br /> Assessor's p y�- <br /> WELL Location 1"�"-' Cross Street ity Zip 5 37 W/Parcel# L4'0�-ib 1 <br /> PROPERTY Owner tt✓ S� J ` Add`n/:ssZ8,4b �S itY Zip 5�y37LPh,nesth,� r(Ofq <br /> C-57 Contrassor dyes `fi5 Gv/ ad_Ci CF��JyC� hone# <br /> Consultant/Sub Contractor l�v�-�l 1� Address ri�ZF]��(�city Lim' 1 I�9 Phdnei?'63?--7--4-7)1. <br /> Gfflr �r'�`'7cE� <br /> GIS Coordinates:X Y Township Range ection <br /> iiWORK TO BE PERFORMED <br /> EW <br /> WELL/BORING(CPT. GEOPROBE,HYDROPUNCH, HAND-AUGER.OTHER-) a DESTRUCTION(choose type below) <br /> SOIL BORING# a OVER-BORE <br /> WELL"— !!:2! a PRESSURE GROUT <br /> -Other. <br /> C CMMENTS: <br /> EYP=_OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br /> VNITORING iOLLOW STEM DIA.OF 30REHOLE MULTIPLE CASINGS?, 'E5'(j NO WELL CASING DIA: <br /> Z)XITRACTION ��nAIR!-WMMER/DRIVEN CASING THICKNESS I TYPE OF CASING: Q STEEL PVC OOTHER <br /> VAPOR Ej MUp ROTARY DEPTH OF GROUT SEA! I i REhAIE TYPE TO BE UScD:�TUGERS QHOS E <br /> AIR SPARGE © PUSH POINT GROUT SEAL PUMPED: GYies a No {NOTE: MAXIMUM FREE-FALL DEPTH IS 30'} <br /> ] SOIL BORING 0 HAND AUGER APPROX.BORING DEPTH F,ta,561LETEDTRAFFIC BOX a, 0 STOVE PIPs <br /> OTHER: CONDUCTOR CASING PROPOSED? if.YES.list specifications here): <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS! <br /> I hereby cenifv that I have prepared this application ano that the woes will be bone in accomance with San Joaquin County Ordinances,State Laws,and Rwes <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 WORKMAN'S COMPENSATION Laws of California." Contractors hiring or sub- <br /> contracting signature certifies the following: 7 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 California.' <br /> THE APPLICANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed x <br /> � AAO&t Title � `v '1� Date <br /> SEE SITE MAP IN UNIT IV WORK PLAN. DATED <br /> PARTMENT USE ONLY l u� V1 �/!� Area f�f <br /> Application Accepted By Date Issued / <br /> Grout Inspection By Date C Final Inspection By Date <br /> Destruction Inspection By 6 Date <br /> COMMENTS I CONDITIONS: <br /> ' ACCOUNTING ONLY: AID# FACT <br /> I <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#1CASH 'RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICc <br /> 0240qz <br /> - <br /> VN17 EV-5/99/MI <br />