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WELL PERMIT APPLICATION FORM <br /> UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION ("PHS-EHD") <br /> 304 E. Weber, Third Floor, Stockton, GA., 95202 <br /> (209) 468-3450 <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 /> rC Assessors <br /> San Joaquin County Development Title.Chapter 9-1115.3 and the Standa//his of San Joaquin County Ou(�F tNZa rvlcaS� ,Env'rAssess al Hea1N Division. <br /> WELL Location y o W_chi V / W all Cross[,rStreet Irl itL —C'ty Cit /Pt.X� ZipSlP-a6 Phone#t <br /> PROPERTY Owner ^10 Address 1 y0 y > qq //`` u 1 <br /> 14 G�G 71VI4 Q �y o An,,r'l��ZiPl�licil0.%�/0� Phoneajdf-3l3 <br /> Th51tu Addressy�� ��Gr_ &d Rd <br /> C-57 Contractor / S' City A�IA'bU4 L;c# Phone[t707-Y_ 3s yxsz <br /> Address�70 pLL ,,VLS ? <br /> Consul[ant/Sub Contractor /V Range section�� <br /> GIS Coordinates:X, ... <br /> Y Towrnship��— <br /> WORK TO BE PERFORMED 0 DESTRUCTION(choose type below) <br /> p OVEBORE <br /> 0 NEW WELL I BORING(CPT,GEOPROSE. HYDROPUNCH.HANG-AU ERR <br /> .OTHER') PRESSURE GROUT <br /> )fSOIL BORING# L r- <br /> WELL# <br /> -Other: <br /> C,-MMENTS: <br /> 7,pE �L CONSTRUE CONSTRUCTION SPECIFICATION <br /> F BOREHOLE d MULTIPLE CASINGS? YES ONO WELL CASING DIA: _ <br /> DIA.O <br /> 0 MONITORING o HOLLOW STEM TYPE OF CASING: 0 STEEL i]PVC 0 OTHER: <br /> HAMMER/DRIVEN CASING THICKNESS TREMIE TYPE TO BE USED: GAUGERS OHOSE <br /> D EXTRACTION AIR HADEPTH OF GROUT SEAL <br /> 0 VAPOR p MUD ROTARY , y� U No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301 <br /> PUSH POIN f GROUT SEAL PUMPED: 0 0 BOLTED TRAFFIC BOX or U STOVE PIPE <br /> 0 AIR SPARGE APPROX. BORING OEPTH�� <br /> (SOIL BORING 0 HAND AUGER If YFS, lis[specifica[ions here):�- <br /> CONDUCTORCASINGPROPOSc07 ( <br /> OTHER: <br /> COMMENTS: <br /> NOTE: OFFSITE BO[RINGSaREQUIR E ACCESS �BENS ROACHMENT�rPEcRMIT Saws,and Rules <br /> I hereby certify the[t have prevarad this app 9 S: y P <br /> and Regulations of the San Joaquin County- Homeowner or licensed agenCs signature certifies the following; f cetif that in t5a erfcrr..a^ce of the worts. <br /> ns subject to V <br /> for <br /> o wh,'Cng this <br /> ignaeurercerlifies the following:tl certify theft inemploy othe Performance of the work for Owh;ch this Permit is ssued.1 of sha�ews mployoPersons subject ro suh- <br /> WORKMAN'S COMPENSATION Laws Of Cefifomia.' <br /> /^� THE AP ANT MV57 CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTION . <br /> Zi <br /> /L _ �LM Titl r Date <br /> Signed DDD GN�f1�N�• "�r <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED n� 1 ll <br /> DEPARTMENT USE ONLY u0 Areai — <br /> ALA,\ Date Issued Date_ <br /> Application Accepted By Dale .0 Final Inspection By <br /> Grout Inspection By Date <br /> Destruction Inspection By <br /> COMMENTS I CONDITIONS: <br /> FACS <br /> ACCOUNTING ONLY: AID# <br /> ERVICE <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKftlCASH RECEIVED BY DATE REQUEST NUMBER INVOIf <br />