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DATE RECE ED BY <br />FAC* <br />ACCOUNTING ONLY: <br />PE CODES <br />"2?kfc2 <br />A10* <br />AMOUNT REMITTED FEE INFO CHECK*/ ASH <br />qR# <br />INVOICE PERMIT/SER_VICE REQUEST NUMBER <br />9-22-1999 A:00PM 1-RUM <br />WELL PERMIT APPLICATION FORM <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 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 ;n 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. Assessors <br />WELL Location 4S 5 VA.4e-v-Coo Roa, Cross Street City fo CA4-(Y1 Zip Parcel* <br />PROPERTY Owner Ect.l. CY\ ey,...k-cverlgo Address V). 0 • Box -7869 City 13(A-Y10 . Zip 9 l50 I Phone # 47 45 - 9301, <br />C-57 Contractor \!\ < /CIA Address 950 •kif1V4e.- RA • City R.7•Airkiv‘i I Zip 94%3Licg 50.07Phonell (926) 31a -6600 <br />Consultant Sub Contractor CtIcW\Va-knZt. 6n.ii.04Kit4Address 210 P•cr --‘t S Sf-• City -S011154110l. Li c* Phone* (-10.1) 933 2-3(ve <br />Section <br />WORK TO BE PERFORMED • <br />0 NEW WELL / BORING (CPT. GEOPRO6E. HYDROPUNCH. HAND-AUGER. OTHER') <br />\a/SOIL BORING * (UT- I) <br />a WELL tt <br />UNIT IV <br />GIS Coordinates: X . Y Township Range <br />\A) <br />13 DESTRUCTION (choose type below) Ul <br />0 OVER-BORE <br />(I PRESSURE GROUT <br />'Other <br />COMMENTS: <br />TYPE OF WELL CONSTRUCTION TYPE <br />0 MONITORING 0 HOLLOW STEM <br />a EXTRACTION 0 AIR HAMMER/DRIVEN <br />u VAPOR 0 MUD ROTARY <br />3 AIR SPARGE v215iJSH POINT <br />1,2-101L BORING 0 HAND AUGER <br />3 OTHER: <br />CONSTRUCTION SPECIFICATIONS <br />--...- <br />DIA. OF BOREHOLE 2" MULTIPLE CASINGS? 0 YES 0 NO WELL CASING DIA. <br />CASING THICKNESS 1,4A TYPE OF CASING: B STEEL 0 PVC 3 OTHER: <br />DEPTH OF GROUT SEAL (0' TREMIE TYPE TO BE USED: a AUGERS [NOSE ----- <br />GROUT SEAL PUMPED: tee-S a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />APPROX. BORING DEPTH 90 a BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? 1"-1 0 ( if YES, list specifications here): <br />COMMENTS: <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 Ordinance's. State Laws, and Rules <br />and Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: "I <br />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: <br />'I certify that in the performance of the work for which this permit is issued. I shell employ persons subject to <br />WORKMAN'S COMPENSATION Laws of California.' THE APPLICANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />fltle 1;:0). 6-et.lcil‘ct)ate 9 -28 —0 t <br />SEE SITE MAP IN UNIT IV WORK PLAN DATED 8- (;,— 0 <br />C,/ i - Area <br />_Date 11v v 2 <br />) <br /> 7W I Final Inspection By <br /> <br />Date <br /> <br />Date <br />COMMENTS / CONDITIONS: <br />Signed x <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />EPARIMENTJJSE ONLY <br />Date Issued