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k,,:;:;; =' Ire WELL PERMIT APPLICATION FORM <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> \ ^ <br /> �Q�,L ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> O <br /> 2 304 E. Weber, Third Floor, Stockton, CA., 95202 G'Q <br /> ' (209) 468-3449 60-12-- <br /> NON-REFUNDABLE <br /> 0-1ZNON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application Is hereby made to San Joaquin County for a permit to construU andlor Install the work described. This application is made in compliance wllh San <br /> ' Joaquin l Health <br /> County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Envlronme Assesso sDlvlsion. <br /> 2i <br /> cL�/✓n CI !- p <br /> WELL Location �rs�✓ Cross Street��i�✓ ty <br /> PROPERTYOvmer G'i oY- T./a-� Address j2o Trr..cy�i✓Gl Cfry TlG ZIpJ�3� Phone# Z49 5?1`/(o Z7 <br /> 9OG�Lo Ci i CLp9 .�Llc#y8s?�SPhone#9Z S31J,5580� <br /> C57 CantraU rlG il�✓t Address / �y s Z o0 <br /> Consultant!Sub Contracto�l�/✓/l�G�lll� � Z LIC <br /> -��/` "rCi 95�le # Phone#9/G <br /> e* ddress <br /> GIS Coordlnales:X-46 -337. /08�1�Y1�1 Township 62S Range oSE Section <br /> WORK TO BE PERFORMED: <br /> DESTRUCTIt choosetypebelow) <br /> ' NEW WELL 1 BORING(CPT,GEOPROSE.HYDROPUNCH,HAND-AUGER,OTHER') OVER-BORE <br /> o SOIL BORING# a PRESSURE GROUT <br /> C WELL# <br /> Other: <br /> ' COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Q MONITORING 0 HOLLOW STEM DIA OF BOREHOLE MULTIPLE CASINGS?0 YES U ND WELL CASING DIA:_ <br /> ' TYPE OF CASING: O STEEL 0 PVC C OTHER: <br /> U EXTRACTION AIR HAMMER/DR_IVEN CASING THICKNESS TREMIE TYPE TO BE USED: I]AUGERS OHOSE <br /> o VAPOR l]MUD ROTARY DEPTH OF GROUT SEAL <br /> U AIR SPARGE a PUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> Q SOIL BORING U HAND AUGER APPROX BORING DEPTH 0 BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> ' OTHER: fl OTHER CONDUCTOR CASING PROPOSED? (If YES,Ilst spe-Mcat(ns here): <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> w,,il[be donewna=!�anoo with and Rn County Ordinances,btale Laws,and Rules <br /> b co tions of the San Joaquin County.Homeovmahoto 'wall licensed ag nt's signature cergfiass the folllloWing:an 9/lcerifly that In the perlormame of the work <br /> RKERS'COMPEN <br /> contract)9 signature certifies the following: or sub- <br /> t'I certfoy palmons Subject toify that in the penamiance ofhe work for whichthis permit Is/$suedof !(/shalaemploy persorns sub/ed fo <br /> ' WOR MPENSA77ON Laws ofCalifomla.' <br /> ` CA L THE UNIT IV INSPECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS ✓ ; <br /> cf0 <br /> '1416,TltlelCaiJie.r�TQ ��o%`✓•r� <br /> Sign mpa <br /> -- tl <br /> Print Name <br /> SEE SITE AP IN UNIT N WORK PLAN DATED: z 7 D2- �j�Gav <br /> ' DEPARTMENT USE ONL <br /> Dere lesued �' 3 Area <br /> Appticallon Aaepted Final Inspection By Data <br /> Grout inspec5an By mare <br /> ' Destruction lnspecdon By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AJO# ; <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKII, RECD BY DATE P <br /> E REQUEST= INVOICE <br /> ' 9oy w� 555 s- i oo2gbg6 <br /> 5/15/2000 € <br /> � Id EEVEBBV60Z 6L 9T 000d/6t/50 <br /> E0 39Vd i <br />