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Al� WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES Off ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) DI ' ' �lE COP Y <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 for a permit to construct and/or install the work described. This application is made in compliance with <br /> San Joa uin Coynty Development Title Chan tgr 9-1115.3 and the Standards of San Joaquin Count ubl' H alth Services, Environmental Health Division. <br /> LA- ���� ,. �w�Cd n �t� Assessor's <br /> WELL Location In i QTGHT-OF-W A`(+r Cross Street& "r Zip Parcel# Rutl <br /> PROPERTY Owner SAN SgA(lJtiJ c<),,jntTY Address ItSin F HA2ELI,)A AYE City STOCK3DiJ Zip $Z%5 Phone# (¢oy)468-34yq <br /> RANCHO <br /> C-57 Contractor CA5CAOE DP:TLLLhIf Address 36,2 OMEC CIAC-LF Cityco2ocYg Zi pgv,-r42Lic#712510 Phone#!a16J B-I (,9 <br /> ADJANCHD GSC- <br /> Consultant/Sub Contractor Address 3250 - NII RD. City_5sQcK1_QNLic# Phone# (mn)yt.D-tc--j- <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> NEW WELL/BOR IyE PT, GEOPROBE, HYDROPUNCH, HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> 6 0 SOIL BORING# 0 OVER-BORE <br /> (Q &WELL#KW -l5,202A.22. 23 240 0PRESSURE GROUT <br /> 'Other: <br /> COMM ENTSApFFER ENC-E ATTACii rJORk PL-INN DATED 15 3ANVARY <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING )KHOLLOW STEM DIA.OF BOREHOLE $ " MULTIPLE CASINGS?➢f;YES 0 NO WELL CASING DIA: Z ,r <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS so AFou-c4o TYPE OF CASING 0 STEEL ',KPVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 1-I'AS(: TREMIE TYPE TO BE USED: AUGERS OHOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: $Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH So'ANO RO )a BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER:_0 OTHER CONDUCTOR CASING PROPOSED? NI A (if YES,list specifications here): <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, State Laws,and Rules <br /> and Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: "I certify that in the performance of the work <br /> for which this permit is issued, I shall not employ persons subject to WORKERS'COMPENSATION Laws of California." Contractors hiring or sub- <br /> contracting signature certifies the following: "I certify that in the performance of the work,for which this permit is issued, /shall employ persons subject to <br /> WORKERS'COMPENSATION Laws of Califomia." <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signedx 18tr�yJ JA-y_ Title/Company STPFF CCZENTZST/Attu aNcp wcc 'TAMPtATAL <br /> Print Name P ECLY LEE Date 2-12,310-1 <br /> SEE SITE MAP^ IN UNIT IV WORK PLAN DATED. <br /> // <br /> DEPARTMENT USE ONLY <br /> Application Accepted By `1, �- Date Issued a aV et�( <br /> Grout Inspection ByDate Final Inspection By to <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# Ou/ E • -�I <br /> PE CODES=FEE AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> so 15-V 6 g' <br /> 1/18/2000 <br />