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,r .a <br /> WELL PERMIT APPLICATION FdRM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES}+:7- SFRV�1CF <br /> ENVIRONMENTAL HEALTH DIVISION ("PHS-4yD")) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95 ��L 29 PM 4105 <br /> (209) 468-3450 <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 /> 13640 4� I� Assessor's <br /> � <br /> WELL Location / / _r^ Cross Street Ciry 2rp5jS3zl� Parcel# <br /> PROPERTY Owner�Lj +gj�l1'-/f rfr`-% Address Ci Zip ,Phone# <br /> C-57 Contractor 91F(J l�r. <br /> ���. /Addres // �r Ci�Zip 4Lic#.7 �f�Phone# - <br /> Consultant/Sub Contractor AxY �AAaat�Adoress 52(„m( CityfLic# Phone# 579 st^/sL <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> l�' W WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) _ G DESTRUCTION(choose type below) <br /> ,�AOILBORING# Ox-t G OVER-BORE <br /> G WELL# ' G PRESSURE GROUT <br /> 'Other. <br /> COMMENTS: <br /> TYPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br /> Q MONITORING G HOLLOW STEM DIA.OF BOREHOLE r"MULTIPLE CASINGS?a YES Q NO WELL CASING DIA: <br /> G EXTRACTION G AIR HAMMER/DRIVEN CASING THICKNESS— NA– TYPE OF CASING: G STEEL G PVC G OTHER: <br /> G VAPOR G MUD ROTARY DEPTH OF GROUT SEALS":;o`_TREMIE TYPE TO BE USED: G AUGERS CHOSE <br /> G AIR SPARGE p4-PUSH POINT GROUT SEAL PUMPED:,g Yes G No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING G HAND AUGER APPROX.BORING DEPTH2�-7j jj G BOLTED TRAFFIC BOX or,G STOVE PIPE <br /> G OTHER: CONDUCTOR CASING PROPOSED? ri-r5(if YES,list specifications here): <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 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 WORKMAN'S COMPENSATION Laws of Califomia." 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 /> WORKMAN'SCO ENSATION Laws of California." <br /> H PP_ ICANT MUST CALL 48 HRS IN ADVANCE FOR <br /> C FOR ALL REQUIRED INSPECTIONS. <br /> _ <br /> Signed x Title _Wd 2 f._(-JA" Date <br /> SEE SITE MAP IN NIT IV WORK PLAN. DATED % g-egiol <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Issued �d3 Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> FAC# <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#ICASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> UNIT IV-6/18/99/sign bkpg/MI <br />