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WELL PERMIT APPLICATION FORM 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 ORIGINAL <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 /> Un-SiTt rb'h1 CF)A'f AL. Avi. -i-NnAn7orn 80A/) Assessor's <br /> WELL Location-PAG PA Cr—, C14ovRon Cross Street Ctj�,-+M AI%-e Cay taD2 'zip 95aVz Parcel# oS5 -3zr, -Z'. <br /> PROPERTY OwnIe'r1R iva AIRED IJnK iDES Address 64al CAYt�AL Ar,i , City L12 zip9 yL Phone(--, 5 -9330 <br /> C-57 Contractor Wi 5 /-HA2- MA I AddressV5S F1'424Prc to CRY"-co ZIp957ya Lic#55V979Phone# 9 3 7�?7b <br /> lV. WilSen <br /> Consultant/Sub Contractor ACT Address -40CIS WA Cay 5Tp`LK7On Lic# Z2 Phone Zr,r /on (� <br /> GIS Coordinates:X ,Y ,Township Range C �Section�� <br /> WORK TO BE PERFORMED <br /> NEW WELL/BORING PT GEOPROBE, HYDR PU , HA -Al GER,OTHER-) 0 DESTRUCTION (choose type below) <br /> OIL BORING# NC `" i '/''r 0 OVER-BORE <br /> 0 WELL# / Q 0 PRESSURE GROUT <br /> Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLEZ-i�)a MULTIPLE CASINGS? 0 YES ONO WELL CASING DIA:Nilp <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS Nlq TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: NIG) <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL Tcl A L 19 OP TREMIE TYPE TO BE USED: 0 AUGERS MOSE <br /> 0 AIR SPARGE ,JPUSH POINT GROUT SEAL PUMPED: Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPT I 30') <br /> -31L BORING a HAND AUGER APPROX. BORING DEPTH 15 0 FE 4 4-- 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> O` OTHER: 0 OTHER CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br /> COMMENTS: [)ASFr) Of\ CPI 'N/1'nc: 5 A ii no, 7v57ere0 hvZIIS b•rl)) be )✓S'IALL£tp <br /> T <br /> c.,-) A L,9 1F kQ (kr;.P. A T TI-1 i S PP4 Le- <br /> NOTE: <br /> e.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: Rcertify that in the performance of the work <br /> for which this permit is issued,1 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, I shall employ persons subject to <br /> WORKERS'COMPENSATION Laws o/California." <br /> HE APPLICANT MUST CALL 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed x Title AD;QCf G('<' o Date A 3 -Z Z -c o <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED: <br /> DEPARTMENT USE ONLY may/ D <br /> Application Accepted By Date Issued ! '7-DU Area <br /> Grout Inspection By Date Final Inspection By l!rnapp+�r,, 4� Date <br /> Destruction Inspection By tl Date C0.Z77LE D <br /> COMMENTS/CONDITIONS: <br /> ell <br /> ACCOUNTING ONLY: AID# PArti <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 350 ffivi 1 3/ 'Z DZ?i 5 <br /> C-57 LICENSED CONTRACTOR MUST SIGN LICENSE &WORKERS' COMPENSATION DECLARATION <br /> UNIT IV- 6/23/99 /sign bkpg/MI <br />