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- � 1 • FILE COPY <br /> UNIT IV <br /> WELL PERMIT APPLICATION FORM <br /> AUG <br /> 15 2001 � i <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES l <br /> i"!TH ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> r,lliCtS <br /> - 304 E.Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Appliratlon is hereby made to San Joaquin County for a permit to what andlor install fhe work descnLed. This application Imsesspompliance with <br /> San Joaquin County Development Tide,Chapter 9-11115.3 andel he Standards Of San Joaquln Co/u�nt�y Publi��HeehhZServices� Environmental sz HY51� Division. <br /> �S <br /> fIl �I— It Cfo55 Stns �114V i � .City'n .J77 / I#.�14r 7 7 <br /> WELL Location //``yy�� // �J / Phone#!!� <br /> //1�,,//��� z✓)110 6 Address M 6 <br /> PROPERTY Owne)l�&r � s54/"/9 ph� <br /> 1' Addres <br /> �. ctO �9eTs94�3 /3¢S <br /> cny —ue# <br /> Addressz0 <br /> ;7t <br /> I S"Contractor � <br /> Section <br /> Y ,Township Z �--Ran� <br /> � <br /> GIS Coordinates:X , <br /> c� /1 A <br /> WORKTO RE PERFORMED /Q �]Qd S�VQ✓�O-�qK ZO` 1 1 k X31 � � 9/T O� <br /> ( i P! Q DESTRUCTION(choose type below) <br /> V NEW WELL I BORING(CPT,GEOPROBE,HYDRO(I INCH.)AND-AUGER,OTHER-) 8 OVER-BORE <br /> L,! oOIL BORING 00 PRESSURE GROUT <br /> 'VM <br /> LL <br /> C <br /> -Other: <br /> S'�e CY Ind <br /> COMMENTS ft D�QLPi1�yn{"UlzflS j <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> HOLLOW STEM DIA.OF BOREHOLE S!.MULTIPLE CASINGS?0 YES NO WELL CASING DIA: <br /> MONITORING TYPE OF CASING: O STEEL `QYPVC p OTHER: <br /> 0 EXTRACTION 0 AIR ROTA RIDRIVEN CASING THICKNESS / <br /> 0 VAPOR D MUD ROTARY DEPTH OF GROUT SEAL N <br /> TREMIE TYPE TO BE USED: AUGERS OHOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes No OTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING 8 HAND AUGER APPROX.BORING DEPTH <br /> BOLTED TRAFFIC BOX or U STOVEPIPE <br /> (d YES,ilst specifications here): <br /> OOTHERt OOTHER <br /> CONDUCTOR CASING PROPOSED? <br /> COMMENTS 5:1t1-k11 <br /> ✓ <br /> NOTE: OFFSITE BORINGS RE ACCESS OR ENCROACHMENT PERMITS te aws,and Rules <br /> I hereby certify that I have prepared this application and that the work will be done In accOrdanCa with San Joaquin County Ordinances, <br /> and Regulations o1 the Sen Joaquin County. Homeowner or It Mad agent's signature certifies the following: -I cardfy char a the P�°��ns 5ring of tsub- <br /> contracting c siis s plumf certfes the I'o bw np:tl cel that employ sons Sul in the peAamenc����W wh�Sh Pew s!sued,ATION Laws Of CaI!shalt emP oY pe 9is h4irring pr sub- <br /> WORKERS'COMPEN TION laws of Ca6famla ; ' .pIREI)�IN.` ._r 1xs5 <br /> A4.`" OR::4$ �.�7K1 ADVA�951".+W °a v <br /> G Tftle/Company 4 n "/�' <br /> goes x _Q <br /> l( 5 S Date <br /> Print Name ///////����1///�Q(�((�� / <br /> DEPARTMENT USE ONLY !��9—t>� Area-0—W', <br /> Date Issued r <br /> Application Accepted BY DataFinal Inspection By Date <br /> Grout Inspection 8Y Dale <br /> Destruction InspectlOn By <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT 15ERVICE REQUEST# INVOICE <br /> ?fro �I•� 52 z,�-8 Gu-� &'�5 �/�8/z� <br /> Z0 39tid <br /> 800-U H1dId EEVE891760Z LE:CT 000Z/9Z/40 <br />