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. WELL-PERMIT APPLICATION F,.0 n M UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION {PHS-EHD}° p <br /> t< 304 E. Welder, Third Floor, Stockton, CA 95202 D <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San,Jeaquin County for a permit to construct and/or install the work described. This application is made in compliance wit:'- <br /> San Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services. Environmental Health Divis,c,; <br /> tI1I�11 _ Assessor's, L,,WW w <br /> WELL Location I�ZI $eao�Cs�d� ` Qa Cross Street Rasa MC4.0%^ . City ']Sto�V.Aa,^ Zip���� Parcel# (14t l c ._OT-D <br /> pay i `, <br /> PROPERTY Owner + Ic�c1v� �+►���+�� �rt�o` Actress tg3Z tS.E� �•��1 r ®�: City S�O V_ o.�. Zilpis2d� Phone <br /> PROPERTY <br /> C-57 Contractor Q!W oo•x\�A, \`K.- Address tors•'6x y16 cityAAI�1 <br /> Consultant Sub Contractor ZL S54cvu - s kteAddress%1+1 Low&Wft 1i lit)( Il'tLl� 6 Lic# <br /> GIS Coordinates:X Y Township ZA1 *Range : _Section ` <br /> WORK TO BE PERFORMED i 'S <br /> 0 NEIN WELL I BORING{ CPT, GEOPROSE, HYDROPUNCH, HAND-AUGER, OTHER') d DESTRUCTION (choose type bafcw) <br /> 0 SOIL BORING# 0 OVER-SCBE <br /> WELL# W t a d PRESSURE GROUT 1 <br /> •Other: � '� <br /> 1 <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ,r <br /> MONITORING ''HOLLOW STEM DIA. OF BOREHOLE 6 MULTIPLE CASINGS? 0 YES NO WELL CASING DIA: <br /> Q EXTRACTION G AIR HAMMERIDRIVEN CASING THICKNESS Sc.-% A() TYPE OF CASING: 0 STEEL 0 OTHER. � <br /> (�VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 'Z6 TREMIE TYPE TO BE USED: 0 AUGERS ICSF <br /> p AIR SPARGE p PUSH POINT GROUT SEAL PUMPED: VYes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> p SOIL BORING Q HAND AUGER APPROX. BORING DEPTH �S `� -- Br]LTED TRAFFIC BOX or STOVEPIPE <br /> OTHER:_0 OTHER -CONDUCTOR CASING PROPOSED?4` 40 o (if YES, list specifications here): <br /> vp 1 <br /> 4 � <br /> a} <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS ' <br /> t hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, State Laws, ar.d fies Rules <br /> and Regulations of the San Joaquin County. Homeowner or licensed agent's signature certithe following: "I certify that in the performance cf t`e work <br /> for which this permit is issued,1 shall not employ persons subject to WORKERS'COMPENSATION Laws of California." Contractor's hiring or S <br /> contracting signature certifies the foilowing: "1 certify that in the performance of the work for which this permit is issued, I shall employ persons su..,Fect rc <br /> WORKERS'COMPENSATION Laws of California " lig <br /> CALL THE NIT IV INSPECTOR 48 WORKING HRS IN ADVANCE FCR ALL REQUIRED INSPECTIONS. <br /> Signed x 7itlelCompany <br />` Print Name <br /> Date I <br /> I SEE - SITE :MAP r IN UNIT 'IV:WORK;PLAN DATED <br /> D PA TMENT USE ONLY] <br /> Area—,�-- <br /> Application Accepted 8y � . to Issued i � _4 <br /> , <br /> Grout Inspection By Date f00inal InspectiohpBy Date—__ <br /> Destruction Inspection By1 Date <br /> -CM TS! ONDITIONS: <br /> i ACCOUNTING ONLY: AID# ✓ <br /> PE CODES FEE INFO AMOUNT,REMITTED CHECK# REC' Y DATE PERMIT I SERVICE REQUEST# INVOICE <br /> CE <br /> lizsizaoa <br /> �L <br />