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WELL7)PERMIT APPLICATI"ON F6�M UNIT IV <br /> SAID JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION ("P:HS-EHD") <br /> 304 E. Weber,-Third Floor, Stockton,-C,4 95202 <br /> (209) 468-3450 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> - _ - II :L <br /> # Application is hereby made to San Joaquin County for a permit to construct and/or install the worts 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 Pudic Health Services,Environmental Health Division. <br /> ' '11 Assessor's <br /> '•,�.� III Zips Parcel#' <br /> . <br /> WELL Location � h2a�1�n�� Cross street a city � <br /> PROPERTY Owner <br /> Arg �urg_ Address 1�,71i 13&±e'Lw9�'J City 5 p l4 ad hp` # <br /> C-57 Contractor l_k,mvt_.itJwamass City 11 Zip Uc# Phone# <br /> } Consultant!Sub ContractordJ( s 405 [}• Q W-A)u1y!I City57aC�-Lim Phone# I <br /> GIS Coordinates:X_ Y Township ' Range Section l <br /> WORK TO BE PERFORMED <br /> NEW WELL I BORING (CPT.GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) Q DESTRUCTION(choose type below) <br /> SOIL BORING# 8.1 '� _ a OVER-BORE <br /> WELL# a PRESSURE GROUT <br /> 'Other. <br /> C--MMENTS: <br /> i YPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS n �,!'' j <br /> G MONITORING 1ZHOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?o YES NO WELL CASING DIA: Al 4- � <br /> '� E)CTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS NR- _'TYPE OF.'.CASING: a STEEL p PVC p OTHER: 1J4 I <br /> i,VAPOR d MUD ROT ARY DEPTH OF GROUT SEAL S r I� TRF-MIE TYPE TO BE USED: D AUGERS. CHOSE <br /> AIR SPARGE p PUSH POINT GROUT SEAL PUMPED: a Yes -)(No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> ;� <br /> ] SOIL BORING a HAND AUGER APPROX.BORING DEPTH S T[�5 BOLTED TRAF=lC BOX or STOVE PIPE <br /> OTHER: CONDUCTOR CASING PROPOSED? l-/JA I'(if YES,list specifications here): s <br /> i� <br /> i <br /> COMMENTS: <br /> 1' II I <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS? 1 <br /> I hereby certify that I have prepared this application and that the work will be done in accorraanci 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- 3 <br /> contracting signature certifies the following: 7tify certhat in the performance of the work for which this permit is issued, !Sha/!employ persons subject to <br /> WORKMAN'S COMPENSATION taws of California.' <br /> ,�7THE APPLICANT ST CALL 48 HRS IN ADVANCE FOR.'ALL REQUIRED INSPECTIONS. <br /> I <br /> # Signed x Title � "r G�acoa�fr- Date 9��195- — <br /> E <br /> SEE SITE MAP i NIT IV WORK PLAN. DATED i <br /> DEPARTMENT USE ONLY <br /> C` Application Accepted By Date lssbed _ — Area <br /> Grout inspection By '1 Date al Inspection By Date 1 <br /> Destruction Inspection By Date I� i <br /> COMMENTS I CONDITIONS: I Dt P moi- <br /> f <br /> IIkx - <br /> l� <br /> u ;FAC# <br /> IACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED <br /> I RECEIVED BY LATE ; PERMITISERVICE REQUEST NUMBER INVOICE f <br /> SR9 <br /> - <br /> i, UNrT ry-5199/Mr I' <br />