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WELL PERMIT APPLICATION FORM UNIT IV LoP <br /> <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 />ai eA WELL Location 2 Wt-trio-0 35 <br /> <br />idok_rtn 4 40, I ons((..22!Dit S44/45-SentreetectiOr I*7:4116/(til "r01/14Address Voy 040 tif <br />5 <br />1(5 City Cdc-t Lic# v <br />C-57 Contractor (AJ Or/ t( Address PO (1,074 City ke4„,,, <br />17,40,-/ T„ <br /> z,pcf5WL.#-Izoloy-phone# <br />GIS Coordinates: X Township 1- 2- t`J Range <br />Cross Street Sierra. L vs, . City 540C-k.40101, Zip <br />PROPERTY Owner (.4 /1-rmAitar 10,c. Address6Z5 W061476-115+' Citytketi41 CA" Zi q3/40Phone P <br />9 <br />pho„,A(0 4 <br />R( e <br />7- <br />Section <br />Assessor's <br />Parcel# <br />ORIGI1AL. <br />5 <br />-14- I op <br />If 5 <br /> <br />WORK TO BE PERFORMED <br />NU NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />SOIL BORING # <br />ELL # A9 s - -2, , - t t <br />eArl cr-1"-D, 51,4-Q *Other: —11-7.4.)-o t" <br />COMMENTS: <br />0 DESTRUCTION (choose type below) <br />OVER-BORE <br />[I PRESSURE GROUT <br />TYPE OF WELL <br />It-MONITORING <br />I] EXTRACTION <br />0 VAPOR <br />LAIR SPARGE <br />SOIL BORING <br />[I OTHER: <br />INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />'HOLLOW STEM DIA. OF BOREHOLE 01` MULTIPLE CASINGS? U YES )(NO WELL CASING DIA: 04- <br />al <br />0 AIR HAMMER/DRIVEN CASING THICKNESS tj LIO TYPE OF CASING fl STEEL )(PVC t] OTHER: <br />0 MUD ROTARY <br />0 PUSH POINT <br />HAND AUGER <br />OTHER <br />DEPTH OF GROUT SEAL se,e 651A4•44•*45REMIE TYPE TO BE USED: U AUGERS OSE <br />GROUT SEAL PUMPED: Yes U No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />APPROX. BORING DEPTHS69 C491A.4.‘44“4.ts )50.0LTED TRAFFIC BOX or 1:1 STOVE PIPE k <br />CONDUCTOR CASING PROPOSED? NO ( if YES, list specifications here). <br />COMMENTS: 1136-1( L'A4.5 AQ..0-145 q` A-s s. ' tAK) 1 90 <br />T;20-pitk aprt-tAt .• A5 -1 1, C9 As-3 ,. i-5 tvW-- tc 25 I <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 />PPLICANT MUST CALL 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INS ECTIONS. <br />Signed x 49r( 30/.4 6-kv7t;eN atte-CddiTitle 1?-2,3 le-v-a 60-41 /41—Date k 1q00 , <br />SEE SITE MAP IN UNIT IV WORK PLAN DATED: A44)iii22.0-1 811Bizcoo <br />DEPARTMENT USE ONLY <br />Date Issued Application Accepted By <br />Grout Inspection By Date Final Inspection By <br />08 • 2.4- • 2-)C'C' Area CDg4-di <br />Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# <br />FAC# <br />_ <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE ---11PE INVOICE -I-S€RTTCRQ51# <br />3f-rt, ; 101,X) FTC?. 51(0 <br />C-57 LICENSED CONTRACTO4 MUST SIGN LICENSE &WORKERS' OMZNSATION DECLARATION <br />UNIT IV - 6/23/99 /sign bkpg/MI <br />‘4.57. <br />Destruction Inspection By Date 2MPLETED