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1 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 /> NON-REFUNDABLE PERMIT EXPIRES t YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct andlgr install the work described. This application is made in compliance with <br /> San Joaquin County Development Title, Chapter 9-1415.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division <br /> 1 3$275 We.I IZ Ur 1 Assessor's <br /> WELL Location `f Grass Stre^et� Nw�, 33 City t/ernwl.g Zip �S38S Parcel# aSrJ- 1`SO-rr <br /> PROPERTY Owner .���^r1 t'T�'^'kz� Address ; ln,✓�� lJ+"�„J z- Gity z�'� yLta Zip�� ra Phone# <br /> ® C-57Contractor�Ure-r;� D.-ii1,n� Address qSO ��o4c!e �r1. City/`tu:Ein.e Zip9`15�3Lic#yF5/6�Phone# l� 3t3.-SO, <br /> Consultant Sub Contractor <br /> Crermarrtit (n^Sc. c� Address ZiOi ILr_ S� 1'r-'f . City &,kI Ad Lilt Phone#.{510�(<. s-11]�rj <br /> GIS Coordinates:X Y Township Range Sedion <br /> WORK TO BE PERFORMED <br /> NEW-WELL BORING CPT,GEOPROBE, HYDROPUNCH, HAND-AUGER. OTHER') `DESTRUCTION(choose type below) <br /> JxSOIL BORING# GKX- GMX-9_LLIX-It) - 3 Ix+�;n r 1-101I0t. S M” a OVER-BORE <br /> o WELL f3vrj ro evitecl Soi i )(PRESSURE GROUT <br /> -Other: S c. w Q �� — G <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> t,tOtJITORING HOLLOW STEM � D;A.OF BOREHOLE f0 Ire.. MULTIPLE CASINGS?o YES XNO WELL CASING DIA: AIA <br /> EXTRACTION Q AIR HAMMERIDRIVEN CASING THICKNESS A14 TYPE OF CASING: 1]STEEL [I PVC ❑OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL Q111 bL btli�TREWE TYPE TO BE USED: AUGERS } )�iOSE <br /> p AIR SPARGE p PUSH POINT GROUT SEAL PUMPED: Xyes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS,30') <br /> SOIL BORING G HAND AUGER APPROX. BORING DEPTH 10' _ -tV' I] BOLTED TRAFFIC BOX or O STOVE PIPE <br /> a OTHER: I) OTHER CONDUCTOR CASING PROPOSED? n/A (it YES,list specifications here): <br /> COMMENTS: D l► 3 L" ci�a, . t7c-in`C L.J� 1-Ic l L-d 0'.-A tvgtA _ 2 ]o '. fc11r <br /> 5011 „S(,IrlPUA d-Lgl eld-b fir+ .'i1 t+,+ t.2N1P1 ut . It^ta ve rr it t e <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 fol;owing: "1 certify that in the performance of the work <br /> for which this permit is issued,1 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 shalt employ persons subject to <br /> WORKERS'COMPENSATION Laws of Califomia." <br /> THE APPLICANT MUST CALL 48 HRS IN ADVANCE FOR ALL.REQUIRED INSPECTIONS. <br /> Signed%�f /��+ � d__� T tle� Date <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Issued Area <br /> Grout Inspection 8y Dale Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS i CONDITIONS: <br /> FAG# <br /> ACCOUNTING ONLY AID# <br /> �1 <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#!CASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE <br /> ® C 5? ICEISSED G;OTGTR ivST ' + N,LTCENSE&W'QKI .'.GC}11TvACN'DCLA` .40I <br /> UNIT LV- 6/23/99/sign bkpg/MT <br /> E€E{{B( <br /> 9 <br /> iy <br />