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09-23-1999 08: 17AM FROM TO 19258387425 P.04 <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> 1 SAID JOAQUIN COUNTY PUBLIC HEALTH SERVICES D <br /> le <br /> HEALTH DIVISION ("PHS-EHD") C(a <br /> v� 304 E.Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3450 <br /> NON-REFUNDABLE PERMIT EXPIRES 1-)MR FROM DATE ISSUES FILE <br /> COPY <br /> Application is hereby made to San Joaquin.County for a permit to cort9truG 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 .135`!60- � <br /> WELL Location YOo S• 7RAr'_y ALVQ. Cross Streeet 1W013 L,U City 1$B CX Zo yS 3716 Parcel* 8 <br /> \ Su/7£ lQ0 <br /> `?ROPERTY Owner kYtAAIb NUkES Address )26�j7 AL('0,67A 13LO19 CitySAA!17RNAU_Zip29Y6jPhone#Y16-566-92U <br /> C-57 Contractor KUt11lA,ts 12L1A,6Address 1104 41A)elul LA! CityIPd ZOLicR`/5�3 OPhone#�r�5.6S5-�13 <br /> Consultant/Sub Contractor FAI6€ . TNP• Address)VO/ e060 �HN1'o�lll�itYSAAIIPAAI4tILi�` Phone�y25.43ed-/6l� <br /> GIS Coordinates.X 121#113820 1Y 31,7 3Y5 2 ,Township Range Section <br /> WORK TO BE PERFORMED <br /> Q NEW WELL I BORING(CPT. GEOPROBE.HYDROPUNCH,HAND-AUGER.OTHER-) DESTRUCTION(choose type below) <br /> Q SOIL BORING# j OVER-80RE <br /> 0 WELL* 0 PRESSURE GROUT <br /> 'Other: <br /> COMMENTS: <br /> TYPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SMIFICATIONS <br /> I MONITORING I HOLLOW STEM DIA.Of BOREHOLEI MULTIPLE CASINGS. B YES �O CASING DIA: <br /> a EXTRACTION Q AIR HAMMERfORIVEN CASING THICKNESS TYPE OF CASING: o STEL a PVC a OT HER <br /> 17 VAPOR Q MUD ROTARY DEPTH OF GROUT SEA'_ TREMA=TYPE TO.BE USED: GAUGERS CHOSE <br /> o AIR SPARGE a PUSH POINT GROUT SEAL PUMPED: Yes Q No (NATE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING Q HAND AUGER APPROX.BORING DEPT H A SCM-TED TRAFFIC BOX or STOVE PIPE <br /> a OTHER. CONDUCTOR CASING PROPOSED' (If YES.list specifications here): <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS.OR ENCROACHMENT PERMITS? <br /> I hereby Cenify that I have prepared this application and that the work will be cone in accordance with San Joaquin County Ordinances.State Laws,and Rures <br /> and Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: 'I certify that In lite perYormance of the work <br /> for which this permit is issued,I shall not employ persons subject to WORKMAN'S COMPENSATION Laws of Califomia." Contractor's hiring or sub- <br /> contracting signature Certifies the following:'1 cer*Chet in the pedorman=of the work for which this permit is issLwd 1 shall employpersons SUb/eCt to <br /> WORKMAN'S COMPENSATION Laws of Califomia.' <br /> THE APPLICANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed x�&Iarxt Title rf-&446157 Date <br /> SEE SITE MAP IN UNIT IV WORK PLAN. DATED_ �.zar <br /> DEPARTMENT USE ONLY 4v <br /> Application Accepted By Date Issued /10 <br /> Grout Inspection 8 h Date Final I spection By <br /> Destruction Inspection By Dat '!� ZZ f'LS 9 l0 <br /> COMMENTS/CONDITIONS: • <br /> • <br /> ACCOUNTING NLY: AID# <br /> AC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKWCASH RECEIVED BY DATE P£RMITISERVICE REQUEST NUMBER INVOICE <br /> 2 020 2cP <br /> UNIT IV-5/99/MI <br />