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Signed x <br />Print Name Eiev, A J F)3 L-',2-F Date <br />SITE FILE ADD S ORK PLAN DATE: <br />T IV IN ECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS <br />Title/Company foo`77,2 4J_ <br />MENT P// RECEIVED <br />1 2000 <br />Date Issued <br />Final Inspection By <br />WELL PERMIT APPLICATION FORM <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 />UNIT IV <br />FILE COPY <br />oh! <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 work described. This application is made in compliance with San <br />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 /> Zip c5N205—Parcel#I I737'-Z'7 <br />PROPERTY Owner COI.A..11Z.I.J.-1,1 O'ThialI2-0‹..K.Address 2. ,10 ty 7- -2 Zipeicay)—Phon e# <br />C-57 Contractor SPEC-TR-OA-4 Address City Zip Lic# Phone# <br />Consultant / Sub Contractor F77),/...I. Fk..16/z_ Address 17_79,3 r,D, c-,p, LAC i ty L,01)1 Lic#/q752 Phone#:36p) - y p3 1 <br />GIS Coordinates: X ,Y , Township Range Section <br />WORK TO BE PERFORMED: <br />WELL Location 2211 . tivit Cross Street 9Alat_oct C ty <br />. <br />13 DESTRUCTION (choose type below) <br />13 OVER-BORE <br />El PRESSURE GROUT <br />AftJEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER") <br />13 SOIL BORING # <br />13 WELL # <br />*Other: <br />COMMENTS: <br />7 <br />TYPE OF WELL INSTALLATION TYPE <br />fl-krONITORING 6-14-C-;LLOW STEM <br />0 EXTRACTION AIR HAMMER/DRIVEN <br />VAPOR LIMUDROTARY <br />fl AIR SPARGE [3 PUSH POINT <br />0 SOIL BORING 13HAND AUGER <br />OTHER: 0 OTHER <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE )=3 MULTIPLE CASINGS? DYES 04t5-' WELL CASING DIA: Z <br />CASING THICKNESS S.C.il 40 TYPE OF CASING: 13 STEEL K.42‹ 13 OTHER: <br />DEPTH OF GROUT SEAL Zol- TREMIE TYPE TO BE USED: 13 AUGERS tifer6-S.E <br />GROUT SEAL PUMPED: fiNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />APPROX. BORING DEPTH 5 — 11C3 (1-156-rTED TRAFFIC BOX or STOVE PIPE <br />CONDUCTOR CASING PROPOSED? )() (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 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, I 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 />DEPARTMENT USE ONLY <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />Date <br />Date <br />COMMENTS! CONDITIONS: <br /> <br />al( <br /> <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE I_ls1F0 AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT! SERVICE REQUEST # INVOICE <br />(1-2fil:X"- '1140 sP-7 fi .11, (.4.5 q/i) /OD -SR# _ .._ ....... <br />350 57 exp. WC/waiver C-57 Letter of Authorization to sign permit Encroachment oc s .