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ACCOUNTING ONLY: <br /> <br />PE CODES FEE INFO <br /> 9-22-1999 A:00PM KUM <br />UNIT IV <br />Contractor <br />Consultant / Sub Contractor Ca.riNkritaL \r‘tYllY041Address 210 Per-V-2%.-‘ C4-. City Scrincswa. Licit — phone* (.10-1) 933 - <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 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. Assessors <br />WELL Location 4315 (A1r,-4-e-e400 Riq&c;(- Cross Street City SkIDCV--Csn Zip Parcel* <br />PROPERTY Owner ECktAGY\ EAA-e--1)V;t5e-S Address li).0 • 'box SC,9 city TAA- OceA^Ac Zip c)15C4 Phone* (599 ) 64S -93040 <br />C-57 693 \ C11 Address 950 (4 1C <br /> <br />6tAg-- :Q City \\ka,ANNZ Zip 914553 Licit 4$5149 Phone* (97-5) 313 - So <br /> <br />Township Range Section <br /> <br />GIS Coordinates: X . Y <br /> <br />WORK TO BE PERFORMED <br />v(1,E'W WELL! BORING (CPT. GEOPROSE. HYDROPUNCH. HAND-AUGER, OTHER') <br />OIL BORING <br />XNELL It 3 (Ntu.3 -3. 14w- 0 <br />DESTRUCTION (choose type below) <br />OVER-BORE <br />PRESSURE GROUT <br />'Other <br />COMMENTS: <br />TYPE OF WELL CONSTRUCTION TYPE <br />arVIONITORING (3) velOLLOW STEM g.) <br />3 EXTRACTION 3 AIR HAMMER/DRIVEN CASING THICKNESS 4- scv‘• 40 TYPE OF CASING: 0 STEEL PVC a OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL /" 5 °1 TREMIE TYPE TO BE USED: a AUGERS [NOSE <br />G AIR SPARGE OUSH POINT ( l ) GROUT SEAL PUMPED: ,2-1' es IG No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') ' <br />\'OIL BORING Ci ) 0 HAND AUGER APPROX. BORING DEPTH 10 ' / 0 ' a BOLTED TRAFFIC BOX or 3 STOVE PIPE <br />3 OTHER: CONDUCTOR CASING PROPOSED? No ( if YES, list specifications here): <br />COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS! <br />i nereby 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 WORKMAN'S COMPENSATION Laws of California." Contractors hiring or sub- <br />contracting signature certifies the following: I certify <br />that in the performance of the work for which this permit is issued. I shell employ peacins subject to <br />VvORKMAN'S COMPENSATION Laws of California." THE APPLICANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />Signed x j\-\-1 -r----- C170--Q--- <br />SEE SITE MAP N UNIT IV WORK PLAN DATED 8 - b - 0 1 <br />Dpte Issued ° C* ?fre) c .. <br />PARTMENT SE ONLY <br />Application Accepted B a i Date , ,e0R4inal Inspection By <br />i <br />I <br />Grout Inspection By <br />Date <br />COMMENTS / CONDITIONS: <br />CONSTRUCTION SPECIFICATIONS A /I <br />DIA. OF BOREHOLE 10 "/Z n MULTIPLE CASINGS"'3 YES NO WELL CASING DIA: <br />Title r-rDCk toiS Date 9 - ° <br />Area <br />Date <br />Destruction Inspection y <br />AID* <br />INVOICE IT/SERV10E REQUS'N&JM <br />CHECK/1/CASH AMOUNT REMITTED 00