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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, CA-, 95202 <br /> (209) 468-3450 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> in <br /> Application is hereby made to San Joaquin County for a permit to construIr and/or install Joaquin <br /> work described. This application is onAssessorsntalcompliance Ott+ <br /> 1 l(zS-o3o_u3 <br /> San Joaquin County Development/T�ilia.Chapter 9-11 t5.3 and the Standards of San Joaquin County Pu/bli/c Health Services,Environmental Health Oiwswn. <br /> WELL Location N`/C9 UjP'3T C4,r}e/ tvf - Cross Street t S}f`-City S e..lC rOn ZP <br /> 1 S I A / �! f� `1537 Phone# <br /> Jo��h6- II Address 77 tri a r't C CiIY rr0.c ti ZiP�1 <br /> PROPERTY Owner Phones 775-14 0L ' 3l <br /> �y 0 'iY I Len Zip �/ dl Lit# <br /> 1 L.�wt.t��_Address i,^ R� f oo Y 6A YP.S�O <br /> C•57 ContractorBoA�`� (QJ <br /> ity< �__Ucq Phone# ?l yam" <br /> Chr�/-i. nJrfo.�mL..f`Rddress 17o z[i�r,.,..S FI'ec f C <br /> onsultan 1 Sub Contractor Ranger—Secuon� <br /> J 7owruhip�� <br /> GIS Coordinates:X-�.— Y <br /> WORK TO BE? RPORmED a DESTRUCTION(choose type below) <br /> NEWELW /BORING(CPT. SOIL BOR NG f{OROPUNCH.HAND-AUGER.OTHER OVERBORE <br /> O 0 PRESSURE GROUT <br /> Q WELL If <br /> rtw-I -f o <br /> 'Other: Y w <br /> CC.,-AMENTS: <br /> TYPE OF WELL CONSTRUE CONSTRUCTION LE 10t 'LSpECIRCATIONS <br /> MULTIPLE CASINGS Q YES 1 <br /> t o NO WELL CASING DIA:7 <br /> HOLLOW STEM DIA. OF BOREHOLE I� <br /> �,pAONITORING � -r(a TYPE OF CASING: U STEEL PVC OTHER: <br /> EXTRACTION D <br /> AIR HAMMERIDRIVEN CASING THICKNESS 7REMIE TYPE TO 8E USED: a AUGERS CHOSE <br /> f]VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL g_��� <br /> GROUT SEAL PUMPED: Yes p No (NOTE_ MAXIMUM FREE-FALL DEPTH IS 30') <br /> AIR SPARGE a PUSH POINT r <br /> 17.0 XBOLTEO TRAFFIC BOX or a STOVE PIPE <br /> HAND AUGER PROX. BORING DEPTH 4SU" lust specifications here): <br /> Q SOIL BORING �o f o ^:c t/;1p�CgpONDUCTOR CASING PROPOSED? 11 1(IF VES, <br /> OTHER: t / <br /> COMMENTS Z W <br /> ��l cue Y�S� Yv AUC. <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERM TS! <br /> I nereby certify that I have prepared Nis appllcauon and that the work will be done in accordance with San J9aquin County Ord'man .State Lai <br /> Rules <br /> and Regulations of the San Joaquin Gounry. Homeowner or licensed agent's signature certifies the following: 1 certily that in the ertormanc o e work <br /> for which this permit isissued, <br /> the I shall <br /> h llnnotl certify Matin he SL rmance of rbject to Me work for Owfnich this permitisissued. I ws Of fshalltemploy P Mons s n to sub- <br /> contracting signature 9' <br /> WORKMAN'S COMPENSATION Laws of Cafifomia.' <br /> / ,THE APPLICANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. y" ' <br /> Title -Date <br /> Signed a <br /> �. <br /> x � I 1 I O� <br /> SEE SITE MAP IN UNIT IV WORK PLANDASE TED <br /> LYDATED <br /> DEPARTMENT �bZ ,1ea <br /> Date Issued I Z' O e <br /> Application Accepted By 1 .ti. c— Date r6 L <br /> t� _Date S zt 02. Final Inspection By <br /> Grout Inspection By I ` Date <br /> Destruction Inspection ey <br /> COMMENTS f CONDITIONS: <br /> FACx <br /> ACCOUNTING ONLY: AID>t <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKWCASH RECEIVED BY DATE PERMITISERO REQUEST NUMBER INVOIC <br /> 350( I/Ff� -001 1 1N <br />