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WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 0-3,41, <br /> Q� 2 SIENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202(209) 468-3449 ORIGINAL <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application ihereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with <br /> s <br /> San Joaquin County Development Title, Chapter 9.1115.3 and the Standards of San County Public Health Services,EnvironAssessor)Environmental <br /> earth Division <br /> WELL Location ��L,_ <br /> y ,u-,-I-rt�, Glob F4vd Cross Street R Avt City S L� �✓ 0 Parcel# �2-I �2E �–t� <br /> 0 12- <br /> PROPERTY Owner <br /> "1–�ICvYX1 In C. Address ID22dS W. �r> CityRr4tA».1 Zipet"12?3 Phone#Sd3 1-11- �17`I'5 <br /> q+.}�3 Lig#•{35f6; PhoneK 92-9-31S'"00 <br /> C-57 Contractor(!� 1� � <br /> LW h D W E Address 150 HAVE City i Zip <br /> Consultant/Sub Contractor 1•'-v CDR-p.. Address 400 �T CHILAW f City �jCbR-D Licm�Phone# 97.9E;- �,8 8 <br /> • 2340 <br /> Y <br /> Township Range Section <br /> GIS Coordinates:X <br /> WORK TO BE PERFORMED - <br /> DESTRUCTION(choose type belo�:r! <br /> NEW WELL t BORING(CPT, GEOPROBE, HYDROPUNCH,HAND-AUGER,OTHER') p 0 OVER-BORE <br /> 0 SOIL BORING`P Q PRESSURE GROUT <br /> Q�NELL# <br /> 'Other: <br /> COMMENTS: <br /> TYPE OF WELL <br /> INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS �� <br /> (g�MONITORING Q"HOLLOW STEM DIA.OF BOREHOLE S rr MULTIPLE CASINGS?�YES �NO WELL CASING DIA: <br /> AIR HAMMER/DRIVEN CA GH 4V TYPE OF CASING: STEEL . PVC Q OTHER: <br /> EXTRACTION 0 TREMIE TYPE TO BE USED: Q AUGERS OHOSE <br /> 0 VAPOR MUD ROTARY DEPTH OF GROUT SEAL <br /> Yes No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> PUSH POINT <br /> p AIR SPARGE D ,:BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> Q SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH `1Q <br /> 0 OTHER: O <br /> OTHER SING PROPOSED? (if YES,list specifications here): <br /> COMMENTS: <br /> Z;a:jof.�il,,TA VAiL <br /> NOTE: OFFSITE BORINGS-REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby certify that I have prepared this applica�imeowner�or licensed geat the work will nt's signatureie done in aceriifiest tll <br /> the :"I lowingcertify Countyan Joaquin Ordinances, <br /> that in the performance of the wol rk <br /> and Regulations of the San Joaquin County. H Laws of <br /> for <br /> sub- <br /> contracting this <br /> signature permit <br /> certifies the following:not lemploy <br /> certify thatpersons <br /> in the performance of the work for fwh chsthis perlmit s ssued•1t shall empfoyContractor's <br /> pe sons sub subject tou <br /> c 9 <br /> WORKERS'COMPENSATION Laws of California." <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Title/Company I'f' W <br /> Signed x <br /> Date <br /> Print Name <br /> I►y� •e l e� . <br /> SEE SlT AP IN UNIT lV ;WORK PLAN naTED.r' <br /> DEPARTMENT USE ONLY <br /> /0 Area <br /> Date Issued V j �— <br /> Application Accepted ByC ED Oate <br /> Grout Inspection By Date Final Inspection By <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: • �' <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DAT PERMIT SERVICE REQUEST# INVOICE <br /> 0221 L Z� L S' - <br /> 1 00 a./>si2000 <br />