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WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES LOP I <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) ORIGINAL <br /> 304 E. Weber, Third Floor, Stockton, CA., 96202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUF_D <br /> Application Is hereby made to San Joaquin County for a permit to construct andlwk Install the work described. This application Is made in compliance with <br /> San Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division <br /> Asaeasar's �/ r, <br /> WELL Location 2 t b� Coca tc, I,, Ild Cross Street f:"y(�n City"6,6A_ ZIP_ <br /> IP Parcew /23--ord-2-/ <br /> PROPERTYOwner_(_jwtrw �-a _ Car Address City 5,0:1,Ra.,,2M 21p9'15T3 Phonau74�--gq L- <br /> C-S7 Contractor 6f's ( Vff �n (rTct/angddresa 'Ow'�i'{�,� City���Y,(,�2ip4t/—TLiey LZ 1 PhoneN �� ("L 2 37Y <br /> J r G•TJC <br /> Consultant/Sub Contractor Adtlresa1�J-1 t" f•... ..e�n of Chy IaY687A_PnonaM�l 21--16 <br /> GIS Coordinates:x , Y .Townshlp Range Season <br /> WORK TO BE PERFORMED <br /> WINEW WELL I BORING(CPT, GEOPROBE.HYDROPUNCH,HAND-AUGER, OTHER-) a DESTRUCTION(choose type below) <br /> 0 SOIL BORING& 0 OVER-BORE <br /> P 1 - ❑PRESSURE GROUT <br /> 'Other: <br /> COMMENTS. <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS // <br /> Q MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE Q_MULTIPLE CASINGS?O YES �TJD WWELL CASING DIA <br /> (I EXTRACTION a AIR HAMMERIDRIVEN CASING THICKNESS I) ,Z�,TYPE OF CASING: Q STEEL PVC 0 OTHER <br /> OR Q MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: C AUGERS QHOSE <br /> R SPARGE U PUSH POINT GROUT SEAL PUMPED' es 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 3n <br /> f,011­BORING (IHAND AUGER APPROX. BORING DEPTH �� B r U BOLTED TRAFFIC BOX or U STOVE PIPE ­vIv <br /> a OTHER: O OTHER CONDUCTOR CASING PROPOSED? A )_(it YES, list specifications here): <br /> COMMENTS. <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby teddy that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances. State Laws Ana Rules <br /> and Regulations of Inc San Joaquin County. Homeowner or licensed agent's signature c rtifiss the following, "I cerftyy,that in the performance of the wurk <br /> Iw which this permit Is issued,I shall not employ parsons subject to WORKERS'COMPENSATION Laws or Callfornla." Contractors hiring or suu <br /> contracting signature canifles the following •I calmly fhat rn the pedormanee of rhe work for which this permit is issued. I shall employ persons suti,90 to <br /> WORKERS'COMPENSATION Laws of CalifiCIMIS - <br /> THE APPLI AfffNT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed x Title rhr - Date 1 L �-f <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED <br /> DEPARTMENT USE ONLY Z���/'Q N <br /> Application <br /> lion AccepteIS By _ Dale Issued Area Lob�JY' <br /> Growl Inipeclion By Dale Final Inspection By —Dake-- <br /> Destruction <br /> Dale -Destruction Inspection By Dale <br /> COMMENTS I CONDITIONS: -- — <br /> FAC& <br /> ACCOUNTING ONLY: AID& <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#ICASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE <br /> 501 LW <br /> cal...014 <br /> UNIT IV. 6/23/99 /sign bkpg/MI / <br /> ( j iAr tOP110C . <br /> Z0 39dd d001d H13Id CCPE0911G0Z pS :DI 00UZ/9Z/VU <br />