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RCC,- <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 /> (209y468-3449 <br /> D NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct and/Qr 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 /> WELL Location 35275 WeIEy Rvcul Cross Street <br /> Hwy . 33 City Vcrtlo.lr5 Zip 95385 Parcel# a55� 180'O�I <br /> PROPERTY Owner. ' Address 3l `�/�✓� Or,\le- Cit ve",k�,ek <br /> I y f� Zip qG' Phone', <br /> C-57 Contractor C'rZc)`1 Diilin Address 950 NO\,ve. Qct. CityAcL,/-i�Cz Zip cIY553 Lic#'155/6SPhcne# bfJ313-SBGa <br /> Consultant Sub Contractor Geomi,,LrIX r!o.^,Sv%fatfSAddress 2101 LJzbSff/ S�-.12_9'fV City_DctLic# Phone#Ato���3-�/J�/ <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> )( ELL BORING CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER. OTHER-) `DESTRUCTION (choose type below) <br /> SOIL BORING# GMX- 8r GMX-9, &MX-10 - 3 kx+,),, /-Jolla,.. S i6v, 0 OVER-BORE <br /> 0WELL# F)V "irc eclieck So;) )(PRESSURE GROUT <br /> 'Other: Sc- icn De re ,� Cc e <br /> COMMENTS: w Qty)fr\ ok 31j7/07— <br /> TYPE OF WELL WSTALLATION E CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING HOLLOW STEM (C') DIA. OF BOREHOLE (0 'tn. MULTIPLE CASINGS? 0 YES WNO WELL CASING DIA: AIA <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS /V4 TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL �vlj -TREMIE TYPE TO BE USED: AUGERS ,F- )r OSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: XYes 0 No (NOTE: MAXIMUM.FREE-FALL DEPTH IS,30') <br /> SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH N0' - 70' 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER: 0 OTHER CONDUCTOR CASING PROPOSED? /,JA (it YES,list specifications here): <br /> COMMENTS: 3 C„ clic. . 6,, n4�6 WI WILL-) 51-'m av4yt 2 hc-i %4 fo 706oltez-4 <br /> Se+;/ S4Mr" 4,14 jie/) cl.tefYo�f IO0.ir\5y1 Cy,fJ4 GeMetii �io.•L �(actcl f1N0✓�L /YtMiC Pipe <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 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: "I certify that in the performance of the work <br /> for which this permit is issued,/shall not employ persons subject to WORKERS'COMPENSATION Laws of California." Contractor's hiring or sub- <br /> contracting signature certifies the following: 'I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to <br /> WORKERS'COMPENSATION Laws of California." <br /> THE APPLICAN4NO& ` RS IN ADVANCE L 5tEQUlEt�p,INSP 5IOjV�S,Z <br /> Signed x ✓�~' ? Title_ ec. �: r /Date 1 6 <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED <br /> DEPARTMENT USE ONLY ? <br /> Application Accepted By - Date Issued J��/0Z AreaCU �dS <br /> Grout Inspection By Date � �� Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> FAC# <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> G O a 9 33S <br /> C a7 L�CISE CNTR� TE)R_115`' XGN;LTCEISE& QKE ._� cr Aar_ r > r <br /> UNIT IV- 6/23/99 /sign bkpg/MI <br />