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WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> �� PY- ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) FILE COPY <br /> yr 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (g ` (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 andlor install the work described. This application is made in compliance with <br /> San Jo quin Coun evelopment Title, Chapter 9-Al15.3 and the Standards of San Joaquin County Public Health Services,EnvironmentalAssessrs Health Division. <br /> uFy� e71sv ^ _14459 Tri°FWTfl J oA� e iN'RNioNRo/10 V <br /> WELL Location ^�� <br /> Cross StreetCAP�1AL Avi, City Lon 1. Zip�s'�Y�Parcel# 055-/52`ZS <br /> PROPERTYOwner A;r0AAD 6-KrDfS Address b(O- C LAvf City ZOOS Zip952L--)Phone 20`' 3b7--4330 <br /> d 6 FN:tI <br /> w NA-z- MA I Address SRaci Fi4-L aJQ Rory City Cc RDo.,A Zipfl5l4a Lic#55� 71 Phone# GI(,0355611j <br /> C-57 Contractor EST GL- Wry <br /> ntr-I Zcd 4b7 /ov <br /> Consultant/Sub ContractorLvl,.jcssD £yv't°reI Addressyo05 Al W;15 r� City 3-l'ocKincn Lic#lo`6°L29 Phone# <br /> GIS Coordinates:X <br /> y ,Township J N Range < Section - <br /> WORK TO BE PERFORMED <br /> 'NEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER,OTHER-) 0 DESTRUCTION (choose type below) <br /> /////��---�\��\ a SOIL BORING# 0 OVER-BORE <br /> SWELL# M W-b £ fn w"-r t t" I 1 )� L PRESSURE GROUT <br /> -Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING �OLLOW STEM DIA. OF BOREHOLE_MULTIPLE CASINGS?0 YESO WELL CASING DIA:_ <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESSSC SF0 F `e°�TYoPE OF CASING: 0 STEEL�VC 0 OTHER: <br /> 0 VAPOR D MUD ROTARY DEPTH OF GROUT SEAL �5 F 4 c F 6SGTREMIE TYPE TO BE USED:�(UGERS DHOSE <br /> p AIR SPARGE O PUSH POINT GROUT SEAL PUMPED: Wes O No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING C HAND AUGER APPROX. BORING DEPTH 30 Yfi ` OLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER:_0 OTHER CONDUCTOR CASING PROPOSED? rvu ( 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: "I certify 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: "1 certify that in the performance of the work for which this permit is issued, I shall employ persons subject to <br /> WORKERS'COMPENSATION Laws of California." <br /> JHE APPLICANT MUST <br /> 11 CALL 48 WORKING HRS IN AD NCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed x ro A�� Title r VC T GPC/ }'Date ^0 D <br /> SEE SIT A IN UNIT IV WORK PLAN DATED: a y <br /> DEPARTMENT USE ONLY 15 d Y <br /> Application Accepted By Date Issued 3�)� CV Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS <br /> ACCOUNTING ONLY: AID# [� <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/ ERVICE REQUEST# INVOICE <br /> 3,50 AW l3`f30 <br /> C-57 LICENSED CONTRACTOR MUST SIGN LICENSE &WORKERS' COMPENSATION DECLARATION <br /> UNIT IV- 6/23/99 /sign bkpg/MI <br />