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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 FILE COPY <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 /> (ogp1 C.AP' 'THollty To Cl Apt) Assessor's <br /> WELL Location n i1lALL AvE • Cross Street p;.tgL-. A�e City LOD7- zip ysaya Parcel# 055-32n -2-7 <br /> PROPERTY Owner Ak,9 n kK;,Dz) AddressL42) COP44L AVe• City LOO 1 ZipySZt/a2 phone# Zo°I 3b - 3 p <br /> / IM)rp Sv rl£rl7 <br /> C•57 Contractor . U Address 3315 krn,Ic � Ci[y bz' Zip9254 Lit# $a27Phone 7l 9% 5)b12 <br /> VIX7 <br /> Consultant/Sub Contractor_ A, It , 4 Address_`9 o05 /U, W;),b^ City 51-041-0 n Lic# bn 2 Phone -1nCt V b 7/o o Zv <br /> GIS Coordinates:X , Y ,Township_ Range s, =Section_ J. <br /> WORK TO BE PERFORMED <br /> yd NEW WELL/BORING(CPT GEOPROB HYDFQPUNCH HVjND-A GER,QTHER') p DESTRUCTION(choose type below) <br /> ` IL ING# r'b r P-J11 Y-$ -� I r^/p r/�-ll f�I Z p OVER-BORE <br /> D WELL# p PRESSURE GROUT <br /> "Other: <br /> COMMENTS: 8,,riny,5 Ravcncen To 5 Fee} 65[ �•e 5='I-CRS SAmPI Colltr-T�On <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 4 <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE Q" MULTIPLE CASINGS?0 YES ONO WELL CASING DIA:N I I <br /> ] EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS NIR TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: lv/r+ <br /> ]VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL Too PL DfPT14 TREMIE TYPE TO BE USED: GAUGERS HOSE <br /> ]✓✓AIR SPARGE >9f1USH POINT GROUT SEAL PUMPED: 0 Yes -�I;,Alo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 3'S OIL BORING p HAND AUGER APPROX.BORING DEPTH_ 5 F e a}8brj-0 BOLTED TRAFFIC BOX or p STOVE PIPE <br /> ] <br /> OTHER:_O OTHER CONDUCTOR CASING PROPOSED? (if YES, list specifications here): <br /> -OMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> 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: "I certify that in the performance of the work <br /> 'or which this permit is issued, I shall not employ persons subject to WORKERS'COMPENSATION Laws of California." Contractor's hiring or sub- <br /> :ontracting 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 /> 'YORKERS'COMPENSATION Laws of California." <br /> HE APPLICANT MUST CALL 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed x 6, 1'-Title r 6o(EC_i S pp/c s Date ©34)9 o <br /> SEE SITE A IN UNIT IV WORK PLAN DATED: q <br /> DEPARTMENT USE ONLY <br /> ,pplication Accepted By Date Issued — 13-00 Area <br /> ;rout Inspection By Date Final Inspection By Date <br /> )estruction Inspection By Date <br /> :OMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> FArtt <br /> PE CODES I FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 350i br !3 �`j ' C 3-ta ODZ2,lZS <br /> C-57 LICENSED CONTRACTOR MUST SIGN LICENSE &WORKERS' COMPENSATION DECLARATION <br /> SNIT IV- 6/23/99/sign bkpg/MI _ <br />