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1f7111/Ldl�� 11 54 2994683433 FIFTH FLOOR PAGE 92 <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION ("PHS-EHD") <br /> 304 E. Weber, Third Fl000, Stockton, CA., 95202 <br /> (209) 468-3450 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a Permd to Construct and/or install the work desuibed Thls application is made m c <br /> ompvvith <br /> San Joaquin County Development Title Chapter 9-1115 3 and the Standards of San Joaquin County Public Health Services Environmental Hela thCDiv s on <br /> CITY of MARrECA STA1FEr <br /> 'WELL Location �PtS 0 r- 10 1 pC A ►0 W A V E, E, CS E M I T Assessors <br /> Cross Street Y City �A N I E C A zip gS 33 6 ParcelA <br /> CiT`f' EF MANtEGA h <br /> PROPERTYOwner PUIBLit. WORKS 0VP7, Address OOl Wr%E FSR 5T, C,ty-tADrEtA 41513-4 Phone#(109 x}83-1190 <br /> iC 57 Conlractor MITCHELL ELL DAIIAINCTAddress 10616 MILA'610 WA`( City RANC40 Zrp95670 Lrrl161207 Phonell(916 631-3583 <br /> ConsullantISubContractor CLIAMAGE ENV. CO IigoV <br /> ----�. Address P.O. I3oK $69 City RAN11140 Licttl51=E6 Phone#010351-3150 <br /> GIS Coordinates XM VA l e rA <br /> Y Township-_ Range Stetson <br /> 'WORK TO BEP <br /> 0 NEW WELL I BORING(CPT GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) a DESTRUCTION(choose typo below) <br /> (I SOIL BORING# <br /> 1 WELL S f,1W—9 0 OVER-SORE <br /> Outer a PRESSURE GROUT <br /> COMMENTS <br /> YPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING I HOLLOW STEM DLA OF BOREHOLE S`IN MULTIPLE CASINGS?0 YES ff NO WELL CASING DIA -IIV <br /> 0 EXTRACTION a AIR HAMMERIDRIVEN CASING THICKNESS SCH 4 o TYPE OF CASING 0 STEEL I PVC I1 OTHER <br /> ffOR a MUD ROTARY DEPTH OF GROUT SEAT, 13—FT, TREMIE TYPE YO 8E USEO (;AUGERS OHOSE <br /> SPARGE a PUSH POINT GROUT SEAL PUMPED 0 Yes I No (NOTE. MAXIMUM FREE-FALL DEPTH IS 30') <br /> 8 SOIL BORING a HAND AUGER APPROX BORING DEPTH 30-FT. 0 BOLTED TRAFFIC BOX or p STOVE PIPE <br /> OTHER CONDUCTOR CASING PROPOSED? N (d YES list specifications here) <br /> COMMENTS <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS1 <br /> hereby ceRity that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances State Laws and Rules <br /> and Regulations of the San Joaquin County Homeowner or licensed agent s signature certifies the following "l Certify that In the performance of the work <br /> r which this permit is Issued, I shall not employ persons subject to WORKMAN'S COMPENSATION Laws of Califom/a" Contractor s hiring or sub- <br /> ntracting signature certifies the following -1 Certify That In the performanCa of the work for which this permit is issued,I shall employ porsons subject fo <br /> NVMRKA4AN S COMPENSATION Laws of Cahfonaa " <br /> THE PPLICANT 8 HRS IN ADVANCE FOR R QUIRED INSPECTIONS. <br /> , <br /> ,gned x Title &LI—Cladf- Date.. ? - o z <br /> EE SITE MAP IN UNIT V WORK PLAN DATED 91x6 (01 <br /> f1I EP =NTUSE ONLY <br /> Application Accepted By Cr., Date Issued IC r tea <br /> rout Inspection By4 .r Qat Frml Inspection By � Date <br /> estruction Inspection y Date -. . <br /> COMMENTS I CONDITIONS <br /> FACrr <br /> IjE�)�ES'FES <br /> NG ONLY INFO AMOUNT RENIl1TED CHECKIl1CASH RECEIVED BY D TF PERMIT/SERVICE RPQUEST NUMBER INVOICE <br /> 33- D 2 q 6 1p t�at <br /> IT IV-6/1/99/sign bkpg/MIL <br />