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WELL PERMIT APPLICATION FbRM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <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 Health Division. <br /> QQ �L 4 76 P���s�-�1d -03 <br /> WELL Location 5� Cross Street �A City [ Zip <br /> PROPERTY Owner Address I iIQ MaC _AtR__C' LCi Zip�Phone#g3S s� <br /> C-57 Contractor_ Ae,-C _Address 932 5 tin rd City�,�' ✓' Zip 2/ Lic#�s�dZ7Phone# �67-/O� <br /> Consultant/Sub Contractor 1 € Address X 37 S �afti —City G t' Lic# 6��.27Phone# �67��ad6 <br /> GIS Coordinates:X ;Y Township Range Section <br /> WORK TO BE PERFORMED <br /> 1j(NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH HAND-AUGER,OTHER') p DESTRUCTION(choose type below) <br /> ,SOIL BORING# a- OVER-BORE <br /> 0 WELL# PRESSURE GROUT <br /> *Other.• <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS �> <br /> aMONITORING ]HOLLOW STEM DIA.OF BOREHOLE <br /> t+ MULTIPLE CASINGS?0 YES �'NO WELL CASING DIR."A <br /> 0 EXTRACTION p AIR HAMMER/DRIVEN CASING THICKNESS,_TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR d UD ROTARY DEPTH OF GROUT SEAL u"'rte TREMIE TYPE TO BE USED: 0 AUGERS OHOSE <br /> p AIR SPARGE PUSH POINT GROUT SEAL PUMPED: 0 Yes IRWo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> -V.5011_BORING 0 HAND AUGER APPROX.BORING DEPTH b ` 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> p OTHER: 0 OTHER CONDUCTOR CASING PROPOSED? (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 Ordinances,State Laws,and Rules <br /> and Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: '7 certify that in the performance of the work <br /> for which this permit Is issued,l 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 this permit is issued, 1 shall employ persons subject to <br /> WORKERS'COMPENSATION Laws of California." <br /> THE APPLIC. T MUST CbLL 48 WORKING'.HRS 1N ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed x AAUL Title_ C-le J 4 fS Date -7-31- 01 <br /> Brien Millman <br /> SEE SITE MAD IN 1T IV WORK PLAN DATED: �__ r� r <br /> PERA&TAIENT USE ONLY <br /> Application Accepted By Dale Issued ' Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS l CONDITIONS: <br /> ACCOUNTING ONLY: AID# FACN <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# RE D 4Y DATE PERMIT/SERVICE REQUEST# INVOICE <br /> SDI c� ls,�" 2 §R# 00 2,L <br /> C-57 LICENSED CONTRACTOR MUST SIG 7wr",COMPENSATION DECLARATTflN <br /> UNIT IV-6/23/99/sign bkpg/MI <br />