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' WELL PERMIT APPI�NiTIV U <br /> LICATION FORM <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) mb <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 p <br /> (209) 468-3449 <br /> W- I <br /> NON-REFUNDABLE PERM rr EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application Is hereby made to San Joaquin County for a permit to construct andlor Install the work described. This appticaton is made In compllanco with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental <br /> as altthsDivision. <br /> WELL Locatlon:FS✓� Cross Street%T��iry Tr�7UP 3G Parrslk Zf'6-/3D 6g <br /> PROPERTY Ovme�/11A�� �-edT.t, a dessFSI��O Co �d Cty 7�a�-� ZIp9S GPhare#Zo98Z6/�615 <br /> C-67 Contract orGr i viA Address�pSd lTdtye CiNe✓& e�Zip/`1/•533 Uc#�$S/GSphane#�1S-�r3'S'�A� <br /> SVY9Slc Leo �L <br /> Consultant I Sub Contractor/*'f'4,? aY/4.&? 04 �PV Address��P f�''�'�� Ciry�.lerr✓N LIe# Phone#�6 !�JJ2GSSG <br /> GIS coordinates: dZ,$ Range �Sz- Section 33 <br /> / T'�{ /e8�f ,YLor ,Township <br /> WORKCTO BE PERFORMED: \ ' <br /> %DESTRUCTION(choose type below) <br /> ' DNEW WELL BORING(CPT,GEOPROSE,HYDROPUNCH,HAND.AUGER,OTHER') ��/777 ���(J...```OVER-BORE <br /> D SOIL BORING# Q� yhrRESSURE GROUT <br /> DWELL# <br /> Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTIONsPECIFlCATlONS <br /> D MONITORING D HOLLOW STEM DIA OF BOREHOLE MULE OF CASINGS? <br /> CASINGO D STEEL YES ONO <br /> D pVCLLO OTHERDIA:_ <br /> DEXTRACTION D AIR HAMMERIDRIVEN CASING THICKNESS TREMIE TYPE TO BE USED: DAUGERS OHOSE <br /> O VAPOR a MUD ROTARY DEPTH OF GROUTSEAL <br /> D AIR SPARGE U PUSH POINT GROUT SEAL PUMPED: D Yes D No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> TFIAFFIC:BOX or <br /> ' O SOIL BORING D HAND AUGER APPROX.BORING CONDUCTOR CASING PTROPOSED? (IIff YES,,IisU STOVE PIPE <br /> speclfications;hate): <br /> D OTHER: R OTHER <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> llqt cl <br /> I hereby aano �hisap � a. he lNfiesthe following:"i certy that Inthe performance of the work <br /> and Regulations t the San lyHomeownerlicensed agent's signature <br /> for which <br /> hit tsignature t Is Issues the I$half"following:t'lcettity that In the arrtormencee 5uhl&ct to ofthe wedr for whicthis 1pa ION s issued,Of California'" <br /> shall employersoons subject to <br /> ' WORKERS'CCMPENSAIION Laws of California.' <br /> LL THE UNIT IV INSPECTOR 48 WORKING HRS IN ADVANCE FOR ALL/REQUIRED/INSPECTIONS rcf <br /> �� Yeo TltlelComParry�.�ior �"f Y1 G� �oNrT��/�%�F�" l <br /> Signed x / I <br /> Print Name ��ni-S LACs Data �/9`yZ <br /> ' SEE S MAP IN UNIT IV WORK PLAN DATED: <br /> DEP ENT USE ONI5-- 3- 0 Z� Area <br /> Date Issued <br /> A?plicagon Accepted BY Fnal Inspector By Date <br /> Grout Inapecton By Date 3 <br /> Destruetan inapedtan B Date a <br /> COMMENTS I CONDITIONS: 3 <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK i RECD BY DATE P <br /> E REQUEST i INVOICE ; <br /> ' 4a 2 (A1 (0 0 555 5- on 6g <br /> 5/!5/2000 <br /> /5T/50 <br /> �IW-U HU.�IJ EEVE89PSOZ 6S:5S 000Z <br /> Ee �vd <br />