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2-10-2000 1 1 : 24AM FROM P. 1 <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 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 1} S, RV -S010 4t/onuti- Cross Street w Cit S Zip S�A6 Parcel# <br />�— 1 <br />PROPERTY Owner U nTes� _Address / / -1 ! 111144 r,, �IJ111 _61ty Sr n Zip ) )D Phone#2D F-2- 636 <br />C-57 Contractor I I 1 Lill �i (', ��-ti9 F—M, Address ILL 1% I"ti l �Jal _Cityzip—l' Lic# Phone# -3 > <br />Consultant / Sub Contractor C &1rL LJP-1 Address_)11 le,,j/G Lv lvio 4 ic# Phon <br />U; 3 b ^ <br />GIS Coordinates: X Y Township Range Section wA <br />WORK TO BE PERFORMED \ 1 <br />XNEW WELL / BORING ( CPT, GEOPROBE. HYDROPUNCH, HAND -AUGER, OTHER") Q DESTRUCTION (Choose type below) % J' <br />SOIL BORING # Q OVER -BORE <br />i WELL PRESSURE GROUT <br />"Other, <br />COMMENTS <br />D,�I P �ek1()G J�✓ %Jry e' �o47�il�a.ti c4 S ex <br />TYPE <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />p MONITORING HOLLOW STEM DIA. OF BOREHOLE �C r.. i' )MULTIPLE CASINGS? o YES NO WELL CASING DIA �• �, ,� <br />)(EXTRACTIO1 j] AIR HAMMER/DRIVEN CASING THICKNESS S" - '' `tU LTYPE OF CASING' a STEEL � PVC 0 OTHER. <br />VAPOR 1 0 MUD ROTARY DEPTH OF GROUT SEAL �, L fu`s TFtEMIE TYPE TO BE USED: 0 AUGERS OHOSE <br />)(AIR SPARGE—SP-1 Q PUSH POINT GROUT SEAL PUMPED: 0 Yes D No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER APPROX, BORING DEPTH f f 15 fr BOLTED TRAFFIC BOX or p STOVE PIPE <br />$OTHER: O OTHER CONDUCTOR CASING PROPOSED? IJ (if YES, list specifications here): <br />COMM <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br />I hereby certify that I have prepared this application and that the work wit! 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 Califomia " Contractor's hiring or sub- <br />contracting signature certifies the following: "I certify that in the perfonnance of the work for which this permit is issued, i shall employ persons subject to <br />WORKERS" COMPENSATION Laws of California,' <br />CALL THE UNIT IV INSPECTOR 48 WORKING HRS IN ADVANCE FOR. ALL REQUIRED INSPECTIONS. <br />Signed x_ ,�)Z 2 - Tdte/Company, {�-�-Li <br />Print Name L Cann 1211'"Ltu'r�ctn Date <br />DEPARTMENT USE ONLY <br />Application Accepted By i - Date Issued I I I C, 1 6 Area <br />Z- ti Final Inspection B e 3y <br />Grout Inspection By Date Y Dat�o � <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: I AID# <br />PE CODES I FEE INFO I AMOUNT REMITTED I CHECK # <br />L <br />REC'D BY I DATE I PERMIT I SERVICE REQUEST # 1 INVOICE <br />?��� C�(:C�C.SR# ��`.� <br />