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WELL PERMIT APPLICATION FORM UNIT IV <br /> Z S1 <br /> 2� SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ol�- (�,5 <br /> 'Oi �uG ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) , Z41 <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 �`�' X Z' <br /> . (209) 468-3449 ORIGINAL <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 Joaquin County Devel p nt itle,Chapter 9.1115.3 and the Standards of San/Joaquin County Public Health Services, Environmental a Health Division <br /> m�h-h�„:Glub Siyd Cross Street �� A4 City S L ZiP��✓� Parcel. ��-21 -b� <br /> WELL Location2 <br /> -I_�ICy-�� Iv�C. 1022t�S W. El City�r'�Iar,dORf <br /> Zip°f1Z73 PhonemS03. 9"1'7•`]7y5 <br /> PROPERTY Owner Address �! <br /> C-57 Contractor AR-e(36 qz.A -W44-Address 150 Ho W6 AVE City A= Zipq'+6-53 Lic#48516L Phone# `i 2-�•313.5$00 <br /> 2 Phone# R?r• x,88 234 <br /> Consultant/Sub Contractor ST GoR-P•. Address�5 Fcy-T CHry1Ho" City w L4bXt> Lic#f�_ <br /> GIS Coordinates:X <br /> Y Township Range Section <br /> WORK TO BE PERFORMED <br /> DESTRUCTION(choose type belov;l <br /> NEW WELL!BORING(CPT, GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') 0 OVER-BORE <br /> 0 SOIL BORING# M——�- a PRESSURE GROUT <br /> QNELL#t S lA7-�r-*-rte <br /> �*Other,:ENTS: <br /> • <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS u <br /> � Z- <br /> �MONITORING HOLLOW STEM DIA. OF BOREHOLE 8 " MULTIPLE CASINGS. 0 YES WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING NESS5444 1W TYPE OF CASING: 0 STEEL ,KPVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUTS AL 71 TREMIE TYPE TO BE USED: 0 AUGERS OHOSE <br /> - Yes p N�MOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 AIR SPARGE D PUSH POINT <br /> HAND AUGER OX. BORING DEPT . ,IBOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 SOIL BORING D if YES,listspecifications here): <br /> 0 OTHER:___ <br /> 0 OTHER R CASING PROPOSED. (� <br /> ao h 0 <br /> COMMENTS: Vq- i d I 6 <br /> G <br /> NOTE: OFFSITE BORINGS-REQUIRE A CESS OR ENCROACHMENT PERMITS <br /> 1 hereby certify that I have prepared this County: cation Homeowner or inances,State Laws,and Rules <br /> lice sethe ed agek will nts signatuin re certifies theccordance tfollowing:llan "/certify that iuin County n the performance of the work <br /> and Regulations of the San Joaquin y <br /> for which this permit is issued,/shall not employ persons subject to WORKERS'COMPENSATION Laws of California." Contractor's hiring or sub- <br /> for <br /> contracting signature certifies the following:'I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to <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-r CD r�-Pd �t owl <br /> Signed x <br /> I/ 1 h/1 -ems �ZZ�o t <br /> Print Name Date - <br /> SEE <br /> P. IN UNIT IV WORK PLAN _DaTED:u" <br /> r DEPARTMENT USE ONLY1i C%r` <br /> Date Issued so V Area <br /> Application Accepted By Date <br /> Date Final Inspection By <br /> Grout Inspection By <br /> Destruction Inspection By Date <br /> COMMENTS i CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED ECK# 5E,D BY DATE PERMIT I SERVICE4col&, wow <br /> REQU�fEST# INVOICE <br /> 07002142 <br /> I/18/2000 <br />