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9-22-1999 4:03PM FROM <br />WELL PERMIT APPLICATION FORM UNIT IV <br />01 Au,-, SAN JdAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION ("PHS-EHD") <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3450 <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 />Standards of San Joaquin CountyPublicPublic Health Services, Environmental earth Division. <br />San Joaquin County Development <br />Title, Chapter 9-1115.3 and the nta s <br />-1-1 <br />Mol'--1L1vd C Lx -t C"sQQS,�treet � Zt�'�w�l 'City S -b J- Parcel# <br />WELL Location 00 <br />PROPERTY Owner TK <br />L _Z'P <br />per_ YILS 5ULW1 Address Wb N Shzw Ed • City S-b6&+M Zip 9_ 521�Phone# <br />Dedu`u �1Z <br />KAq <br />ll1 Address �n A01'Q- �' City Yii�� Zip 9iS53Lic#�5%5 Phoneir (925)313 S$oo <br />- <br />''�A <br />C•57 Contractor <br />C1v�n�n� �v,v-evv�Address 21) P�-vk��s S�-• City Se�avna Lic# Phon1#L-1) 935 4850 <br />Consultant Sub Contractor <br />GIS Coordinates: X <br />Y Township Range Section <br />' <br />WORK TO BE PERFORMED <br />NEW WELL I BORING ( <br />DESTRUCTION (choose type below) <br />CPT, GEOPROSE, HYDROPUNCH. 0 D <br />HAND -AUGER, OTHER') OVERBORE <br />Sg_ <br />Vg <br />OIL BORING # \ e`''d 5$-Z <br />Q PRESSURE GROUT <br />Q WELL # <br />'Other. <br />C-�MMENTS: <br />TYPE OF WELL <br />CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br />2 �� MULTIPLE CASINGS? 0 YES Q NO IA. <br />t] MONITORING <br />CLLR OTING HER <br />0 HOLLOW STEM DIA_ OF BOREHOLE <br />THICKNESS �A TYPE OF CASING: 0 STEEL 0 <br />3 EXTRACTION <br />0 AIR HAMMER/DMVEN CASING <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: Q AUGERS 0 HOSE <br />r] VAPOR <br />a MUD ROTARY <br />Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 AIR SPARGE VD BUSH POINT GROUT SEAL PUMPED: 0 <br />APPROX. BORING DEPTH (00" 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />L,21�0IL BORING <br />0 RANO AUGER <br />CONDUCTOR CASING PROPOSED? (if YES, list specifications here): <br />0 OTHER: <br />COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS! <br />I nereby canify 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 WORKMAN'S COMPENSATION Laws of Califomia." Contractor's hiring or sub <br />contracting signature certifies the following: "l certify that in the performance of the work for which this permit is issued, 1 shell employ persons subject to <br />WORKMAN'S COMPENSATION Laws Of California." <br />THE APPLICANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />Signed x <br />Date `� - 3 - O l <br />SEE SITE MAP IN UNIT IV WORK PLAN DATED <br />DEPARTMENT USE ONLY �j Od o <br />Date Issued�7/�.�_ Area <br />Application Accepted Byf// (\ ^�'" I <br />Grout Inspection By �� Date �� �, ` —Final Inspection By( Date <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# <br />PE CODES FEEINFOAMOUNT REMITTED CHECK#JCASH fRIECEIVED BY DATE P ` <br />NUMBER INVOICE <br />3�JI �a-rl � I <br />