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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 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County fora permit to construct and/or install the work described. This application is made in compliance with <br /> San Joaquin County Dw�ogment Title,Chapter 9-1115.3 and the Standards of San Joaquin Couunt�y Public Health Services, <br /> JEnviron <br /> a sormental sHealth Division. <br /> yL[Q /�L� tyq•s Cross Street LI AC.O�Skr City,�L ZiP��b Parcel# !GS"'-D30-d3 <br /> WELL Location_ <br /> PROPERTY OwnerT.` pa S.'n � Address ,T- 5 ' /La/lt City Zip/5-377Phone# <br /> '—� <br /> .. G <br /> ;nexzir7 5 7 <br /> -1 Phone# 125313-SV00 <br /> C-51 Contractor ,- 5 1,5. Address L(. -� �Qzr( 5 <br /> _ 7ti -1133-23` <br /> Sub Contractor_ she . F.."ro1"kA66ress / SCitY m.LidF Phone#' 7 <br /> 9 <br /> — <br /> GIS Coordinates:X <br /> y ,Township Range Section <br /> WORK TO BE PERFORMED <br /> ANEW WELL BORING CPT GEOPROBE,HYD80P NC HANQL6U R,OTHER-) 0 DESTRUCTION(choose type below) <br /> rg SOIL BORING# P - G/! " DOVER-BORE <br /> WELL# Q PRESSURE GROUT <br /> *Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> t <br /> a MONITORING Q HOLLOW STEM DIA.OF BOREHOLEr MULTIPLE CASINGS?n YES 0 NO WELL CASING DIA:= <br /> _ <br /> a EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS —' TYPE OF CASING: 0 STEEL p PVC o OTHER: _— <br /> p VAPOR n MUD ROTARY DEPTH OF GROUT SEAL P�-r'f SDrt�rREMIE TYPE TO BE USED: AAideERSP?t1IOSE <br /> p AIR SPARGE PUSH POINT GROUT SEAL PUMPED: )KYes ONO (NOTE: MAXIMUM FREE-FALL DEPTH IS 3`12111111144r <br /> SOIL BORING p HAND AUGER APPROX.BORING DEPTH 17 Dy p BOLTED TRAFFIC BOX or E STOVE PIPFk <br /> p OTHER: 0 OTHER CONDUCTOR CASING PROPOSED? (If YES,list specifications here): <br /> -cis <br /> COMMENTS: <br /> NOTE" OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby certify that I have prepared this ippllcabon and that the work will be done in accordance with San Joaquin County Ordinances State La s. ules <br /> and Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: "I certify that in the pertormanc the work <br /> for which this permit is issued,I shall not employ persons subject to WORKERS'COMPENSATION Laws of Calitomia." Contractor's hiring 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 of California." <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS.. <br /> Signed x '� Title/Company re4, i4 <br /> l9— <br /> Print Name SCoG1 �l^"�� �y Date <br /> IMuI:� Fr! <br /> DEPARTMENT USE ONLY <br /> Application Accepted By�,'�. rL^ Data Issued O Area <br /> Grout Inspection By 1�M- or. Date O D Final Inspection By n['Oi� Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: _ <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 3so1 IrSltoC SRIa 66 <br /> 1/18/2000 <br />