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f . <br /> f' <br /> WELL PERMIT APPL1 ATION ORM UNIT IV' <br />_ <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DI. ISION,("PHS-EHD") <br /> - 304 E. Weber, Third Floor; Sto kton, CA:,'95202 <br /> (209) 468-345 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public.Health Services,Environmental Health Division. <br /> `� Assessor's <br /> WELT.Location 28� M. "� t L>a � Cross Street in City 5-fbc k t"°1 Zip Parce!#It �. <br /> PROPERTY Owner Amcr'cln mouwLit, Address 28 1 C 17 r City Sof R ZiP Phone# ; <br /> � r1� .Title 'I 5��t1'r <br /> G-57 Contractor ���(/ C7�/� Address J�VYwrIrJM�K �k G h'�—ZiP12$p4 LiGk , Phpne# <br /> Consultant!Sub Contractor Address City Lim Phone#!, _ <br /> GIS Coordinates:X y,,Township Range Section <br /> WORK TO BE PERFORMED <br /> IEW WELL I BORING(CPT GEOPROBE HYDROPUNCH,HAND-AUGER.OTHER'} � � (] DESTRUCTJON(choose type below] <br /> 0 gEG'# 'Z ; _.. ' •'0 OVERBORE <br /> 0 WELL# 0 PRESSURE GROUT <br /> 'Other. <br /> COMMENTS: <br /> TYPE OF WELL CONSTRUCTION TYPE_ CONSTRUCTION SPFCIFICA IONS <br /> 0 MONITORING a HOLLOW STEM DIA. OF BOREHOLE 2 a MULTIPLE CASINGS?a YES *40 WELL CASING DIA: <br /> -X- <br /> 0 EXTRACTION a AIR HAMMERIDRIVEN CASING THICKNESS *Ys <br /> TYPE OF CASING: a STEEL a PVC a OTHER: <br />'+'�* JAPOR�'^�"�"' �1�+tllD ROTArZY }DEPTH.OF.-GROU i..SEA! e�_ _TrZEMIE�TfPc TO 9E.USEQ: .fl AUGERS: �OS=(�/G� <br /> 0 AIR SPARGE �USH POINT GROUT SEAL PUMPED: No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 91!5OIL BORING D HAND AUGER APPROX. BORING DEPTH 50e 0 BOLTED TRAFFIC BOX or a STOVE PIPE <br /> U OTHER: <br /> CONDUCTOR CASING PROP SED? (if YES.list specifications here): <br /> COMMENTS: <br /> NOTE: OFFSITE,BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS! <br /> hereby certify that l have prepared this application and that the worx will be(lone in accordance with San Joaquin County Ordinances, State Laws, and Ruies <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 /> C to WORKMAN'S COMPENSATJON Laws of California." Contractor's hiring or suit <br /> `or which this permit is issued,t shalt not employ persons subje <br /> .;ontracting signature certifies the following: 'I certify that in the performance of the wo for which this permit is issued. I snail employ persons subject to <br /> WORKMAN'S COMPENSATION Laws of California.' <br /> THE APPLICANT MUS L 48 HRS IN ADVANC FOR ALL REQUIRED INSPECTIONS. <br /> Signed x <br /> Title /fu'ec�'LCv(a IS I Dale A LTv� X.1)99 <br /> le <br /> SEE SITE MAP IN UNIT IV WORK PLAN. DATED 2° '`gal 19-95) <br /> DEPARTMENT USE ONLY <br /> Aooiication Accepted By Date Issued �a`fir- . Area d 7S� <br /> Grout inspection By Date Final Inspection By Date <br /> Destruction inspection By <br /> COMMENTS I CONDITIO <br /> - FAC# I <br /> ACCOUNTING ONLY: J`�AIDA <br /> PE CODES FEE INFO AMOUNT REMITTED HECK#CASs{ RECEIVE BY I DATE PERMITISERVICE REQUEST NUMBER INVOICE <br /> I <br /> 3 501 �`� ' if` r l� G �ll�� d f 9 sS-3 .I <br /> UNIT N-5/99/MI <br />