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Application is here <br />Joaquin County De <br />WELL Location 2211 . 11S c-,0 Lvij <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 />y made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San <br />elopment Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />Assessor's <br />Cross Street 9/),P.12.XI2b City C.2(.07011 I zipc79205—Parcel# 17-360 -Z`l <br />ORIGINAL <br />Date Issued 0 C) g4AZU,B,1;1_40 <br />Final Inspection By <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />Date <br />Date <br />DEPARTMENT USE ONLY <br />COMMENTS / CONDITIONS: <br />WELL PERMIT APPLICATION FORM UNIT IV <br /> <br />PROPERTY Owner C013).-"fil-l-)-4 0.-M12.11?...I.Xddress ) ity Zi p cZS,--Phone# .te , <br />C-57 Contractor Address Address <br /> <br />City Zip Lic# <br /> <br />Phone# <br /> <br />Consultant / Sub Contractor FO23-17h-L. a:161z_ Address 17_7c13 c)r)o,fi CIAtt-ACityl-o•DI <br />GIS Coordinates: X ,Township Range Section <br />WORK TO BE PERFORMED: <br />ANEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') 0 DESTRUCTION (choose type below) <br />[I SOIL BORING # 7 0 OVER-BORE <br />fl WELL # 7 <br />[I PRESSURE GROUT <br />COMMENTS: <br />Lic# lq75 phone#2.3 • 1;3 I <br />"Other: <br /> <br />TYPE OF WELL INSTALLATION TYPE <br /> <br />/1-151.0NITORING 6-f16LLOW STEM <br /> <br />EXTRACTION AIR HAMMER/DRIVEN <br /> <br />r] VAPOR ['MUD ROTARY <br /> <br />AIR SPARGE 0 PUSH POINT <br /> <br />SOIL BORING fl HAND AUGER <br /> <br />OTHER: B OTHER <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE S MULTIPLE CASINGS? YES Ro4t5"" WELL CASING DIA: Z <br />CASING THICKNESS S.C.il 40 TYPE OF CASING: [J STEEL Ef444C OTHER: <br />DEPTH OF GROUT SEAL ZC- 75 TREMIE TYPE TO BE USED: B AUGERS 4141.E <br />GROUT SEAL PUMPED: es 13 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />APPROX. BORING DEPTH 9n i -110 11-13 tfED TRAFFIC BOX or 13 STOVEPIPE <br />CONDUCTOR CASING PROPOSED? uz---) cif 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 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: "/ certify that in the performance of the work <br />for which this permit is issued, I shall not employ persons subject to WORKERS' COMPENSATION Laws of California." Contractor's hiring or sub- <br />contracting signature certifies the following: "/ 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 Califomia." <br />LL T IV IN ECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS <br />Signed x <br />Rpr,A41-. ENT <br />Print Name Eialh A I FEOE P EL_ Date ‘.9 <br />SITE FILE ADD S ORK PLAN DATE: k Ab 924 I/ K#/zboc,sEp 7 1 2000 <br />Title/Company to o77tA L. C. ) Li> <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT / SERVICE REQUEST # INVOICE <br />caW( SI 0 ./(„(,,, (-6 witioD -SR# 0.,z.3% . <br />Encroachment oc s . ,3.5D/ 57 exp. WC/waiver C-57 Letter of Authorization to sign permit