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Received Mar-03-00 12:59pm from CCITT G3 4 AQUA NCE page <br /> 3-83-2008 1 :02Pt1 2 <br /> Of P- 2 <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 Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <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 wont described. This application is made in compliance with <br /> San Joaquin County Development Title,Chapter 9-1115.$and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> ,�1 Assessor's <br /> WELL Location �`Sf Y Y'l �-e. �✓4 Cross Street �r City //•�nt1 � ZipL33�- Parcel#^_ <br /> PROPERTY Owner_j rn-./c- 6-!4�►�� Address 34015 N•Ltn;� �) City./'�= �*-� Zip Sj Phone#_ 'S' (o/O-3572,X <br /> C-57Contra.or 1 .I� n Address 95d kkJt-, PW —City �r+l� Ziply553Lit#y55/4SPhone# L-z.5-3/3-$�cC, <br /> Consultant/Sub Contractor tl-v . c• -&n Addross,k"`a' 4 lil 1,,if�:Jei City 925-5J2-0-y3`j/ <br /> Gla Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> 'ANEW WELL/BORING(OPT,GEOPROSE,HYDROPUNCH,HANO•AUGER,OTHER-) 0 DESTRUCTION(choose type belew,, <br /> 0 SOIL BORING# 0 OVERBORE <br /> p WELL# D PRESSURE GROUT <br /> -Othsr: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> $EAONITORING &HOLLOW STEDrt DIA.OF BOREHOLE1� -MULTIPLE CASINGS?Q YES *NO WELL CASING DIA: 7- <br /> 0 <br /> 0 EXTRACTION a AIR HAMMEFUDAiVEN CASING THICKNESS 5y4, YO TYPE OF CASING: U STEEL $QVC Q OTHER; <br /> Q VAPOR a MUD ROTARY DEPTH OF GROUT SEAL G TREMIE TYPE TO BE USED: p AUGERS CHOSE <br /> d AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: Q Yes 84Vo (NOTE: MAXIMUM FREE-FALL. DEPTH IS 30'} <br /> 0 SOIL BORING 0 HAND AUGER APPROX.BORING DEPTH 11 BOLTED TRAFFIC BOX or a STOVE PIPE <br /> D OTHER:_0 OTHER CONDUCTOR CASING PROPOSED? 'Ai (if YES,list specifications here);._� <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby certify that I have prepared this application and that the work will be dome in accordance with San Joaquin County Ordinances,State Laws,and Rues <br /> and Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: 'Y COrt/fy that in the performance of the work <br /> for which this permit is issued,t shall not employ persons subject to WORKERS'COMPENSArlQN laws of California." Contractor's hiring or sub- <br /> contracting signature certifies the following: °I certify that in the perfonne^:#of the work for which this permit is issued, l shall employ persons subject to <br /> WORKERS'COMPENSATION Laws of Califomia." <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HRS IN ADVANCE-FOR ALL REQUIRED INSPECTIONS. <br /> Signed x © �- Title/Company AQ­e, <br /> Print Name _ ftr pa Q z 3�O <br /> SEE, ITE AP fN^UI 1T V_V1, PLAN DATED:: <br /> . ..v. .... ..w... .s • r4 ....� .+ <br /> DEPARTMENT USE ONLY <br /> Aoplication Acceptod By Date Issued Afe M.-i <br /> Grout Inspoct:on By AV1/ Dated tiU11 Final Inspection By ate <br /> Destruction inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY! AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST t! INVOICE <br />