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ci O •7flen.,..s p v-t ;/1 1-0 <br />'11 eve/I-et; <br />Destructio <br />C MMENTS / CONDITIONS 10 <br />WELL PERMIT APPLICATION 1-ORM 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) 468-3450 <br /> <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> <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 />WELL Location q 0.3 /frl'Or-f-A-r - 61C'i Cross Street ni.00( ( City ilitatl --(eeet zipcL>;?-s7 <br /> PA:ses:ors <br />PROPERTY Owner M ge — P6M-1. Address 521 Pt9 1;le- St- City t-t-Tei I ZI.52(-4-Phone#F33 <br />C-57 Contractor /fari/J('-el-a.06/01/24Address 1140-AitiZi7 A->i 1.5-0-7 j City Sitred;>AJLp 9,c 2,4-51.1c# 0)67-27 Phon 7 /6/1)6 <br />Consultant / Sub Contractor S-t-HAZ-a1r /I-- Address37-5-3 6 11-2:74 11---- City /Z/VC&O Li5blek7751 Pt9K1)/rie# ?"'9' -"'5-7 -- 7Z7KL,' <br />GIS Coordinates: X Y Township Range Section <br />WORK TO BE PERFORMED <br />kNEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') 0 DESTRUCTION (choose type below-.:Zi <br />0 SOIL BORING I: 0 OVER-BORE <br />0 WELL # 0 PRESSURE GROUT <br />'Other: <br />COMMENTS: <br />TYPE OF WELL CONSTRUCTION TYPE <br />" ONITORING 0 HOLLOW STEM <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN <br />0 VAPOR 0 MUD ROTARY <br />3 AIR SPARGE 0 PUSH POINT <br />j SOIL BORING 0 HAND AUGER <br />O OTHER: <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE 'VI MULTIPLE CASINGS? U YES 0 NO WELL CASING DIA: <br />CASING THICKNESS TYPE OF CASING: U STEEL VI/C 0 OTHER: <br />DEPTH OF GROUT SEAL 15 TREMIE TYPE TO BE USED: A/AUGERS 0HOSE-Z' <br />GROUT SEAL PUMPED: 0 Yes /8 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30' \ <br />APPROX. BORING DEPTH y,-- Fee-7- OOLTED TRAFFIC BOX or a STOVE PIPE \ <br />CONDUCTOR CASING PROPOSED? Alo (if YES, list specifications here): <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITSI <br />COMMENTS: <br /> <br />tActm•4-4;r2i ,ubiA 'IV 5 1(4--6-(: <br /> <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: "1 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 California." Contractors 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 />WORKMAN'S COMPENSATION Laws of California.' <br />THE APPLICANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />/ / z-2 A Title C-1"0‘.> Date <br />SEE SITE MAP IN UNIT IV WORK PLAN. DATED <br />Application Accepted By <br />Grout Inspection By Date//z/0 iot Xj/g0 Final Inspection By Date <br />Signed x <br />2 <br />DEPARTMENTUSE ONLY <br />Date Issued CO /- - Area CD 7 <br />FAC# <br />ACCOUNTING ONLY: AID# <br />PE CODES FEE INFO AMOUNT REMITTED HE ft/CASH RECEIVED BY DATE PER UMBER INVOICE <br />3 c‘.., t 8- 9 - h;i — lilb0 I e-- Nov R#0 od-rs-Q, - <br />UNIT IV - 5/99 /MI