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WELL PERMIT APPLICATION FORM <br /> UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH Stockton, C PH-E O ) <br /> 304 E. Weber, Third Floor, <br /> 202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM GATE kSSUEDion is made in <br /> Application is hereby made to Sah Joaquin <br /> le Chapter 9-1115.3 xeandt to construct the Standards o Ior install the work San Joaquin County Pulblic Health Servd. This ices,Environmental ssor's Hat <br /> ealth Div s on. <br /> San Joaquin County Development Td p �/ � ZipZ parcel# <br /> N. Dos-eEa�Q Cross Street G ty <br /> WELL Location f Z�. Zip��?v7-phone# <br /> PROPERTY Owner GSR Address3G5 61�`r"`�� G'ty—�� CQZS 313-S�,o4 <br /> !! p �o,� RaC City i,r Zip"SSJLic#41"11 Phone# <br /> C-57 Contractor r b r�{y�n Address . II � _ t{135�, <br /> AlAddress ¢ <br /> �er}tlr3� City�or�_Lic# Phone#L <br /> Consultant l Sub Contracto Section <br /> Y Township Range <br /> G15 Coordinates:X <br /> WORK TO BE PERFORMED 1 <br /> �ES7RUCT]ON(choose type below) <br /> Ll NEW WELL/BORING(CP•T,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') `,OVER-BORE <br /> 0 SOIL BORING# WRESSURE GROUT <br /> 0 WELL# <br /> 'Other: <br /> COMMENTS. <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONSMULTIPLE CASINGS?[]YES 0 NO WELL CASING DIA <br /> VONITORING (HOLLOW STEM DIA.OF BOREHOLE TYPE OF CASING: (]STEEL 0 PVC 0 OTHER: <br /> 0 EXTRACTION 0 AIR HAMMER/DRiVEN CASING THiGKNESS TREMIE TYPE TO BE USED: 0 AUGERS OHOSE <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL, DPTH IS <br /> p AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE:BMA MAXIMUM <br /> FREE-FALL <br /> BOX oLLfl STPIPE <br /> O') <br /> 0 SOIL BORING []HAND AUGER APPROX.BORING DEPTH b <br /> 0 OTHER: 4 <br /> CONDUCTOR CASING PROPOSED? (it YES,list specifications here): <br /> OTHER <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 taws,and Rules <br /> and Regulations vl the San Joaquin County. Homeowner or licensed agent's signature certifies the following: "1 certify that in the performance of the work <br /> ns subject to WORKERS,COMPENSATION Laws of California." Coy persons sub ect to ring or sub <br /> - <br /> for which this permit is issued,I shall not employ perso <br /> contracting signature certifies the following:"t certify that in the performance of the work for which this permit is issued,1 shall employ <br /> WORKERS'COMPENSATION Laws of Calilomia." <br /> CALL.THE NI ]V 1 TOR 48 WORKING HRS IN ADVANCE FOR AL L'REQUIRED INSi?ECTIONS. <br /> . ' 00, <br /> Signed x <br /> Title/CompanyQ� <br /> Date <br /> Print Name <br /> DEPARTMENT USE ONLY t <br /> Date Issued aV Area <br /> Application Accepted By. Dat <br /> Grout Inspection By Date _Final inspection By <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> I <br /> ACCOUNTING ONLY: A1D# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D k3Y DATE PERMIT 15ERViCE REQUEST# INVOICE <br /> 1/18/2000 <br /> FILE. COPY <br />