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t <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> I, <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEAL}TH DIVISION (PHS-EHD) <br /> , <br /> 304 E. Weber, Third Floori� , Stockton, CA., 95202 <br /> (209) 468-3449 <br /> �,,, <br /> NON-REFUNDABLE PERMIT EXPIiRES i 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 Development Title, Chapter 9-.1115.3 and the Standards of San Joaquin County Public Health Services. Environmental Health Divis)on. <br /> f ?l� t.. {{ }} 1 �} <br /> Assessors <br /> WELL Location QJ QY Cross Street W4z v� -city3`6Jklovt Zip Parcel# <br /> PROPERTY OwnerA I esc�a_,4 s So vI- Z;2cAddiess f-0.130x-/�p0� City, ce0 6V d Zip 5�>�.s^/Phone#2/ .gV46 <br /> C-57 Contractor Address.80. ,30x /Z 6-y- _CityKV -; ,j Zip 5ta9/Lic<s/hone#2/ .373`-WS? <br /> Consultant I Sub ContractorcS o� City 4ceMv1lLic#99(0�9ti�hone#530 T9S=�5,� <br /> J� <br /> GIS Coordinates:X ; Y Township Rance Section <br /> WORK TO BE PERFORMED <br /> 0 NEW WELL/BORING(CPT,GEOPROBE, HYDROPUNCH,HAND-AUGER,OTHER") 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# [J OVER-BORE <br /> 0 WELL# ,] PRESSURE GROUT <br /> 'Other: <br /> COMMENTS <br />! TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> JI MONITORING !'HOLLOW STEM DIA, OF BOREHOLE jj .MULTIPLE CASINGS?0 YES 11 NO WELL CASING DIA: y �� <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS_L2, + �IQ, —TYPE OF CASING: 0 STEEL R-OVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: D AUGERS OHOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No {NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH $,BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER--D OTHER CONDUCTOR CASING:PROPOSED? (if YES. list specifications here): <br /> COMMENTS: <br /> il. <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby certity that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances'. State Laws,anc 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." Contractor's 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 s�b1ec<to <br /> WORKERS'CO SATION alifomia' 0 <br /> HE PLI T MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> i. Date, <br /> Si ned x Title_? !fir'��'� — <br /> 9 <br /> SE SIT MAP IN UNIT IV WORK!',- PLAN DATED <br /> DEPARTMENT USE ONLY <br /> Application Accepted By <br /> F Date Issued f 7— Area �4lP Gdl <br /> Grout Inspection By Date " Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: 1/1. <br /> y14 <br /> ,IIS. <br /> FAC# <br /> ACCOUNTING ONLY: AID# i,. <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#!CASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE <br /> Jaz p°=" Cb°� I� � �C � z� o 60>4 ? ? 3 <br /> C-57 LICENSED CONTRACTOR MUST,SIGN LICENSE &WORKERS' COMPENSATION DECLARATION <br /> UNIT IV- 6/23/99/sign bkpg/MI <br /> i <br /> } <br />