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WELL PERMIT APPLICATION FORM <br /> UNIT IV <br /> RECERED SAN JOAQUIN COUNTY PUBLIC HEALTH <br /> ENVIRONMENTAL HEALTH DMS ON (PHS-EHD)S <br /> JUL ?. g 2002304 E.Weber,Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> ENVIRON, ENT HEALTH NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED application is made in compliance with <br /> PERS:.'�/ ���r� <br /> Application is He5� A5md��D San Joaquin County far a permit to construct and/or install the work described. This Services. <br /> er Assessor's <br /> San Joaquin County Development Title.Chapter 9-11115.3 and the Standards off San Joaquin County Public Health QQL_ZSP� yo w Px cels aOH491th-0Division. <br /> Z <br /> 4Q� V G'fcr t�Po� Cross Street $�K1•"n^ City <br /> WELL Location ZiPYS8ZI phone# Zq4� <br /> 1.a ;.�.�1.�S:.w1. AddressZSs�tQ Wa" —Cit <br /> PROPERTY Ows��`• ••�+- — �� p�6.Q d8"65Phonet,�9�Z�'�1�=_S`6� <br /> 4t.. I.�,,.It�• City'g-r'•L"cc-ZiP17�"'U � <br /> C-57 Contractor �t-i 1: Address ! i 1 ep <br /> _ �T_ _-� - 5•f Cry- <br /> Consultant/ <br /> iy- Lic# Z _Phone# cL3— <br /> ddress <br /> Consultant/Sub Contractors Township Range�Section <br /> GIS Coordinates:X �Y� <br /> WORK TO BE PERFORMED a DESTRUCTION(choose type below) <br /> NEW WELL/BORING(CPT.GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') 13 OVER-BORE <br /> p SOIL BORING# a PRESSURE GROUT <br /> WELL# /'44f __V Mte> <br /> "Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> •�riv10NITORING �HOLLO DIA.OF BOREHOLE rr Y+= MULTIPLE CASINGS?0 YES `ad'!O WELL CASING DIA�T rr rl <br /> U EXTRACTION Q AIR HAMMERIDRIVEN DEPTH OF GROUT SEAL OCASING TH ,PE TREM EI TYPE TO BE USED V 0 AUGERSR HOSE <br /> a VAPOR 0 MUD ROTARY <br /> p AIR SPARGE [I 1] <br /> POINT GROUT SEAL PUMPED: 0 Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> OLTED TRAFFIC BOX or 0 STOVE PIPE <br /> p SOIL BORING p HAND AUGER CONDUCTOR <br /> APPROX.BORING DEPTH �• DI ", �ES,list specifications here): <br /> p OTHER: p OTHER CONDUCTOR CASING PROPOSED._� <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby cnd ations of the San ievoJoaql n Chis ounty. Ha'meowner or I ca sed agent's signature certifiesaws and Rules <br /> the'N SaN1ng: "I Certil r Ordi=he State <br /> „ t ecce of the work <br /> for conns Subject to WORKERS'CO <br /> tracting signature lwrtifes the following:`I cerNN than inothe perforrmance of the work for which this perMPENSATIONmit s ssued,ws Of 'I shall employ tp sons subject ect toub- <br /> WORKERS'COMPENSATION Laws of Cafikmfa.” V' <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HRS IN ADVANCE FOR ALL_REQUIRED INSPECTIONS. <br /> A j <br /> ��— "� Title/Companya I <br /> Signed x Date0Z- <br /> ��I4 — �swvwwss _ <br /> Print Name , •: " <br /> PARTMENT USE ONLY <br /> 00 Issued Area <br /> Dale <br /> Application Accepted By Final Insp <br /> Dat . <br /> . <br /> tion By Date <br /> Grout Inspection By <br /> Dale <br /> Destruction Inspection By <br /> COMMENTS I CONDITIONS: <br /> u <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNTREMITTED CHECKS REC'D Y DATE <br /> Q PERMIT 13ROCb REQUEST# /011� <br /> D SO 1/18/2000 <br />