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WELL PERMIT APPLICATION FORM UNIT IV <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES FILE COPY <br />✓' ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209)468-3449 <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 Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division, <br />Assessor <br />NELL Location -1 _J`,r r��/"5'f� ��7Y1 ST Cross Street r:�(S City Zip 7��3�7/��' Parcel# <br />PROPERTY Owner JLN f L&rA4T1;1Address /3� rr�1 E 1 11 Ll a� CityiP-L=Y-a-Phone#�3 / -'� /f;? <br />Iif, Ziu Lic# Phone# <br />GIS Coordinates: X , Y ,'Township Range Section <br />WORK TO BE PERFORMED - <br />.kEW WELL / BORING ( CPT, OP B , HYDROPUNCH, HAND -AUGER, OTHER-) 0 DESTRUCTION (choose type below) <br />SOIL B G # 0 OVER -BORE <br />WELL # _ 0 PRESSURE GROUT <br />'Other: <br />COMMENTS: <br />TYPE OF WELL <br />INSTALLATION TYPE <br />0 MONITORING <br />0 HOLLOW STEM <br />0 EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />0 VAPOR 0 MUD ROTARY <br />0 AIR SPARGE 'PUSH POINT <br />-SOIL BORING 0 HAND AUGER <br />0 OTHER: -0 OTHER <br />CONSTRUCTION SPECIFICATIONS <br />DIA, OF BOREHOLE 1 H MULTIPLE CASINGS? 0 YES E'NO WELL CASING DIA: <br />CASING THICKNESS &D TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />DEPTH OF GROUT SEAL F ! v TREMIE TYPE TO BE USED: e -AUGERS .HOSE <br />GROUT SEAL PUMPED: 0 Yes ,).vo (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />APPROX. BORING DEPTH _�O / 0 BOLTED TRAFFIC BOX or D STOVE PIPE <br />CONDUCTOR CASING PROPOSED? /1�i'i (if YES, list specifications here): <br />L - <br />NOTE: OFFSITE BORINGS REQUIRE AGGE55 UK EIVGKUHL rlitrlr-l4 t rcrcrvll r <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 />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 wh;ch 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 />K(+) Title/Company r77 hdG"" <br />Signed x 0 V � <br />Print Name <br />Application Accepted <br />Grout Inspection By_ <br />Destruction Insoectic <br />COMMENTS <br />DEPARTMENT USE ONLY <br />Dale Issued ��fttrrea�O�q TTA�fegg Area ryct 777 <br />to Final Inspection By 6e l�e <br />ACCOUNTING ONLY: AID# <br />PE CODES <br />FEE INFO AMOUNT REMITTED <br />CHECK #. <br />RECD BY DATE <br />PERMIT/ SERVICE REQUEST # <br />INVOICE <br />1/IR/2000 <br />