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FAC# <br />ACCOUNTING ONLY: Al <br /> <br />PE CODES FEE INFO I AMOUNT REMITTED I CHECK#ICASH RECEIVED BY <br />36o7— 142-2' <br />ER INVOICE DA-- lc I P IT/SERVICE RECUE <br />0 2.50 <br />ORIGINAL <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) 468-3450 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR PROM 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 Develppment The. Chapter 9-1115.1 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />- <br />Assessors <br />WELL Location/CY,/ 'S-12-?-41 Cross Street ae- City (-4-74171.t___ Zip 6-./ S-a ,( Parcel* <br />141—Address Z:erif City Zip Phone#9.57* 83 dig <br />r,> <br />Section <br />OFF COS <br />1NeLL 1122A-- <br />PROPERTY Owner <br />i.- v t I / 07 Address City IS-It' (7k-Lo ch -I 1.1 (Li 7 26): C)Sione# c/74 - 777- 9/ 6`e <br /> <br />ii , , , <br />L i <br /> 130K L f 1 G <br />.2-57 Contractor t I) iv <br />Consultant / Sub Contractor (GT, 4-41:-et L.: cult— - Address i-)-70r- 671) 2- City -51h31--- 4-:*..iC$ 3175— Phone# 7 7Z - 762 C' <br />Township GIS Coordinates: X <br /> Range <br />Pi WORK TO BE PERFORMED <br />3 NEW WELL BORING ( CPT. GEOPROBE. HYDROPUNCH, HAND-AUGER. OTHER') <br />SOIL BORING ;e- <br />a WELL # <br />'Other: <br />*DESTRUCTION (cnoose type below) <br />Xf OVER-BORE <br />0 PRESSURE GROUT <br />COMMENTS: <br />7vbE OF WELL CONSTRUCTION TYPE <br />T-74d1ONITORING `0741OLLOW STEM <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN <br />0 VAPOR 0 MUD ROTARY <br />Q AIR SPARGE 0 PUSH POINT <br />Q SOIL BORING 0 HAND AUGER <br />0 OTHER: <br /> <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE 6. MULTIPLE CASINGS? Q YES NO WELL CASING DIA: '2- <br />CASING THICKNESS O L/0 TYPE OF CASING: Q STEEL Q PVC OTHER: <br />DEPTH OF GROUT SEAL 4-t TREMIE TYPE TO BE USED: 0 AUGERS *CISE. <br />GROUT SEAL PUMPED: a Yes( •?$.No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />APPROX. BORING DEPTH Lt0 0 BOLTED TRAFFIC 30X or a STOVE PIPE <br />CONDUCTOR CASING PROPOSED? (it YES. Iist specifications here): <br /> <br />COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS-I <br />: nereoy certify that I nave prepared this application am: that the work will be cone in a=oroance with San Joaquin County Oroinances, State Laws, and Rules <br />and Regulations of the San Joaquin County. Homeowner Or licenseo agent's signature certifies the following: "7 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 hihng or sub- <br />contracting signature certifies the following: '1 certify that in the performance of the work for which Mis permit is issued. I snail 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 />I ' <br />Tale PI/ _e? c5, 410ate / 2- —e-c) <br />SEE SITE MAP UNIT IV WORK PLAN. DATED <br />Application Accepted By <br />Grout Inspection By <br />Destru ction Inspection By <br />COMMENTS I CONDITIONS: <br />DEPARTMENT USE ONLY <br />Date Issued <br />&yt.e-t 66,/513 ( <br />67 <br />Final Inspection By <br />UNIT v - 5/99 /MI <br /> - <br />07- /b 0/