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s <br />y F <br />WELL PERMIT APPLICATION FORM. _ _ UNIT IV_ <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202_ FILE COPY <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 />f / w �7 ('�' Assessor's1� f <br />NELL Location E5— K)W-S-- J'%%) ST Cross Street ATL tens- City Zip 7037k°_Parcel# A /0.894 <br />PROPERTY <br />P� <br />.31S Coordinates: <br />Range Section <br />'NORK TO BE PERFORMED , <br />�EW WELL/ BORING ( CPT,OP B , HYDROPUNCH, HAND -AUGER, OTHER-) 0 DESTRUCTION (choose type below, <br />SOIL LB G # _. O OVER -BORE <br />0 WELL # _ 0 PRESSURE GROUI <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE <br />0 MONITORING 0 HOLLOW STEM <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN <br />Q VAPOR <br />0 MUD ROTARY <br />0 AIR SPARGE <br />'� PUSH POINT <br />SOIL BORING <br />D. HAND AUGER <br />0 OTHER' <br />0 OTHER <br />Qo/ <br />CONSTRUCTION SPECIFICATIONS I ' <br />.DIA. OF BOREHOLE 2 n.. MULTIPLE CASINGS? 0 YES 10440 WELL CASING DIA: <br />CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC" 0 OTHER: <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: tea -AUGERS r, HOSE <br />GROUT SEAL PUMPED: 0 Yes ,6�uo (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />APPROX. BORING DEPTH .�iO 1 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? NIA (if YES, list specifications here): <br />i <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br />I hereby certify that 1 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 which this permit is issued, I shall employ persons subject to <br />WORKERS' COMPENSATION Laws of Califomia." <br />CALL THE UNIT IV INSPECTOR 48 WORKING HRS IN ADVANCE FOR A)LL REQUIRED INSPECTIONS. <br />Signed x �(,/U(buxx� !L� Title/Company <br />Print Name Date <br />SEE SITE AP IN UNIT IV WORK PLAN DATED Zc� R-•2 <br />DEPARTMENT USE ONLY C / <br />Application Accepted By Date Issued V Area <br />Grout Inspection By Date Final Inspection By Date <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: 'f <br />ACCOUNTING ONLY: <br />AID# <br />PE CODES <br />v <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # -REC'D BY <br />DATE -PERMIT I SERVICE REQUEST # <br />INVOICE <br />Qo/ <br />� <br />— <br />/3&&6 <br />� 0 zzbi� <br />1/18/2000 <br />