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VO <br /> ST Y <br /> WELL PERMIT APPLICATION FORM UNIT IV S <br /> SAN .30AQU1N 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 t]ATE ISSUED <br /> Appacaaon is hereby made to San Joaquin County tar a permit to construct andlor install the work descried 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 Servlces Environmental Health Division <br /> l �,,( L Assessors <br /> WELL LocaUon Z 3 W Sq 5 $rind Cross Street City�r�" v�^h Zip(531,7 Parcelft 3Y2-07 D-10 <br /> PROPERTY Owner OS�. (y�t7l/�O Address Z S"] S. a n Fc ity /'u u[ a nl�Zip y53/. Phone#?N (Y Z6r3 T <br /> C-67 ConiI Ujr,}1lixzm, �lddress3Z33 F•ize4.xid� Sr k3 cityetw'>wu.,)p-,&Zip957I�L 11Y797 Phone#51r 63,3-7Z76 <br /> Consultant!Sub Contractor ycGDZ Z }cry.+ �« wt� Address `•7 qtr ac> '�Ale, !c" ClryP— LIC* (-IOZ- Phone# <br /> GIS Coordinates X Y Township 3 $a.+�, Range­q 64 } Section Z�{ <br /> WORK TO BE PERFORMED <br />�RNEVV WELL/BORING(CPT G]ttg�V)BE,myoROPUNr-W HAND.-AUGER OTHER-) DESTRUCTION(choose type below) <br /> SOIL BORING# p OVER-BORE <br /> 'AWELL# a PRESSURE GROUT <br /> 'Other <br /> COMMENTS <br /> TYPE OF VVELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 4NITORING "A1 )WOLLOW STSM = DIA QF BOREHOLE MULTIPLE-CAS1NG67 p YES F10 VYELLCASING DtA2rr <br /> RAC7[ON Q AIR HAlvttdEFilDrZ[VEM1S CASING THICKNESS <br /> 5CA - L40 TYPE OF CASING p STEEL PVC [I OTHER <br /> POR (}MUD ROTARY DEPTH OF GROUT SEAL / i TREMIE TYPE TO BE USED XAUGERS WHOSE <br /> 0 AIR SPARGE PUSH POINT GROUT SEAL PUMPED NQYes p No (NOTE: MAXIMUM FREE-FALL.DEPTH IS 30') <br /> SOIL BOR91I 0?SAND AUGER APPROX BORING DEPTH ��1 BOLTED TRAFFIC BOX or B STOVE PIPE <br /> 0 OTHEII OTHER CONDUCTOR CASING PROPOSED? U6 (If YES tut spec ifiratlons here) <br /> COM94ENiTS: <br /> • --7 v 401 S <br /> NOTE: OFFSITE BORINGS RE IRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby certify that I have prepared this application and that the trot*w01 be none In accordance with San Joaquin County Ordinanoas,State Law;;,and Rales <br /> and Regulations of the San 403QU[n Courdy Hamcowner or IIcenaed agerifs signature cer ion the folly ring '7 cepOry that in the performance ofthe work <br /> for which this permit is issued,)shall not employ persons stkect to WORKERS'CONPENS49Y01V Laws of QCHbrttla." Contractor's haing or sub- <br /> oontracbng signature cert les the following -f Certify mal In the porfarmarim of the writ*far which thrs permit is issued 1 shag employ persow subject to <br /> AVRKERS COMPENSATION Laws of Cah70mra <br /> fltSrp]ECTOR.433;WP-M�,tkOt IN ADV.A'I CET-9.9 <br /> Yrs+ <br /> Signed x Wz <br /> - - I TrttelCompany 5t'lIL 3 v� rr�e�ice+tsU� Yh[ 4n$� '` "Q - <br /> PrtntNatner�a'cr t1U61v1x.bvti.a Date Z-10-DD <br /> DEPARTMENT USE ONLY <br /> APPGcefion Accepted By Date Issued o Area <br /> Grout inspection Br Date Final Inspection By Date <br /> Dxstructlon Inspection By Date <br /> COMMENTS I coNDi-noms <br /> ACCOUNTING ONLY AID# <br /> CODES FEE INFO AMOUNT REMITTED CHECK I RECD BY DATE PERMIT f SERVICE RlzQUEST# INVOICE <br /> � � p/2�1 7• v oDz3 <br /> 1/18/2000 <br />