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UNIT IV <br /> WELL ERMIT APPLICATION F6M <br /> Y <br /> SAN ,�OAQ UIN 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 <br /> Health Division. <br /> JU. Ad rT J• Cross Street C6-"0 K`t 9ccity 4 N C K 10 V) Zip_#5 x l Parcel# <br /> WELL Location1 dIi <br /> PROPERTY Owner �cl ft r 5�t (ar ' Address �°� -City---------zip Phane# 1' 7 T 7 <br /> M..M fd 'i '�S 7 100 <br /> C-57 Contractor NQuf�a °o ivar�Address DO y �!t sp�1 W'a City 5 I4 !� Zipa5r0If Lic# 6` 0,�� Phone# <br /> Consultant/Sub Contractor �.yL Address City Lic# Phone# <br /> G15 Coordinates:X y,,Township Range Section <br /> WORK TO BE PERFORMED i3l <br /> 0 NEW WELL 1 BORING(CPT, GEOPROBE, HYDROPUNS�H, HAND-AUGER,OTHER') 0 DESTRUCTION(choose type below) <br /> L d OVERBORE <br /> CKSOIL BORING# f 7 <br /> WELL# ,i PRESSURE GROUT <br /> `Other: <br /> COMMENTS: <br /> ` TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS { <br /> a MONITORING 0 HOLLOW STEM DIA, OF BOREHOLE n MULTIPLE CASINGS?3 YES ®NO WELL CASING DIA: <br /> 0 EXTRACTION Q AIR HAMMERIDRIVEN CASING THICKNESS VIA - TY'k OF CASING: 0 STEEL G PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL T. D• Ii TREMIE TYPE TO BE USED: j]AUGERS CHOSE <br /> ' 0 AIR SPARGE UPUSH POINT GROUT SEAL PUMPED: 0 Yes a No(;(NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH D it 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> a OTHER:_Q OTHER CONDUCTOR CASING PROPOSED? N0 ('if YES, list specifications here): <br /> COMMENTS: <br /> Ij <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <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 itie fallowing: "l certify that in the performance of the work <br /> for which this permit is issuer!,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'Ithis permit is issued, l shall employ persons subject to <br /> WORKERS'COMPENSATION Laws of California." Ii <br /> CALL TyyH,��E UNIT IV INSPECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed x kR11 TitlelCompany Ar •f <br /> / <br /> Print Name �1-k vM MW VO <br /> f7 "m Date <br /> SEE SITES 111[AI INUNIT 1V WORKPLAN 17ATED <br /> p DEPARTMENT USE ONLY <br /> Application Accepted By Date Issu Id r 00 Area S� <br /> Grout Inspection By Date Final Inspection-By Date <br /> Destruction Inspection By <br /> Date <br /> COMMENTS I CONDITIONS: <br /> I� <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE I PERMIT I SERVICE REQUEST# INVOICE <br /> . I <br /> 1/18/2000 <br />