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WELL PERMIT APPLICATION. FORM UNIT IV <br /> - SAN JOAQUIN COUNTY PUBLIC HEALTHoEI° '; <br /> ENVIRONMENTAL HEALTH DIVISION (PF` SL <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202SEP <br /> 0 11999 <br /> (209)468-3449 - <br /> 1. ���IMENTAL HEALTH <br /> NON-REFUNDABLE PERMIT EXPIRES 4 YEAR FROM DAT'EW ' I G <br /> Application is hereby made to San Joaquin County for a permit to construct anvvQr install the work described. with <br /> San Joaquin County Development Title,Chapter 9-117 5-3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. i <br /> - Assessor's <br /> " Zip Parcel# <br /> WELL Locationzo Qj Or -S Cross Street VJ6 Cit J <br /> PROPERTY Owner E Address € OQ City.S*Ckla Zi�tSQPhone#G��� <br /> C-57 Contractor c Address [�o�o ! _City Zip A Li��l? Ph.neu/I73 g1 __ 1� <br /> Consultant!Sub Cantracto K 5 f✓'t ddress a 51 city i �bO7gt!jPhone 9 Z <br /> GIS Coordinates:XY Township Range Section <br /> WORK TO BE PERFORMED <br /> j., <br /> p NEW WELL I BORING(CPT, GEOPROBE, HYDR0PUNCH, HAND-AUGER.OTHER`) p DESTRUCTION (choose type below) <br /> SOIL BORING# "I 7 [} OVER BORE <br /> ' <br /> WELL 0 PRESSURE GROUT <br /> "Other: <br /> COMMENTS: €' <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING HOLLOW STEM DIA.OF BOREHOLE_MULTIPLE CASINGS? 0 YES NO WELL CASING DIA: alt <br /> © EXTRACTION D AIR HAMMER/DRIVEN CASING THICKNESS Nck TYPE OF CASING: 0 STEEL © PVC p OTHER: <br /> D VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED:' D AUGERS OHOSE <br /> 0 A SPARGE p PUSH POINT GROUT SEAL PUMPED: B'Yes D No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> a OTHER;_ D OTHER CONDUCTOR CASING PROPOSED? NJ (if YES,list specifications here): <br /> COMMENTS: <br /> i' <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 /> t 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, 1 shall not employ persons subject to WORKERS'COMPENSATION Laws of California." Contractor's hiring or sub- <br /> contracting signature certifies the foliowi g: "l certify that in the performance of the work for which this permit is issued. 1 shall employ persons subject to <br /> WORKERS'CO SAT10N L afifomia."VII <br /> HE L!r' T MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed x - Title+�ZC7 _Date C) /q <br /> SE SI E AP iN UNIT IV WORK PLAN DATED <br />{ I I J DEPARTMENT USE ONLY <br /> Application Accepted By �dtC r Date Issued IV I Area <br /> Grout Inspection By Date lU �� Final Inspection By Date <br /> Destruction Inspection By .Date. <br /> COMMENTS I CONDITIONS: S <br /> - FAC# <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECo <br /> CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> /614"l 62-2 F <br /> C=57 LICENSED CONTRACTOR MUST SIGN'LICENSE&WORKS S' COMPENSATION DECLARATION <br /> UNIT IV-6/23/99/sign bkpg/MI <br />