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WELLERMIT APPLICATION 'M UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES I <br /> ( ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> v 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 7 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 /> I; WELL Location Cross StreetCit Assessor's <br /> City Zip Parcel# <br /> PROPERTY Owner _ Address - City Zip Phone# <br /> C-57 Contractor Address - I <br /> City Zip Lic# Phone# <br /> Consultant/Sub Contractor Address City Lic# Phone# } <br /> GIS Coordinates:X-,Y - ,Township_ I <br /> Range � Section 1 <br /> WORK TO BE PERFORMED I <br /> O NEW WELL/BORING(CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER,OTHER-) O DESTRUCTION(choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE <br /> 0 WELL# <br /> 'Other. O PRESSURE GROUT <br /> COMMENTS. - <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> O MONITORING O HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?0 YES ONO WELL CASING DIA:_ <br /> 0 EXTRACTION O AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL O PVC O OTHER: <br /> O VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: n AUGERS OHOSE <br /> P oIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> UAL BORING 0 HAND AUGER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or <br /> 0 STOVE PIPE <br /> 0 OTHER:_O OTHER CONDUCTOR CASING PROPOSED? (if YES, list specifications here): <br /> I <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, Slate 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 f1 <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: -/certify that in the performance of the work for which this permit is issued, I shall employ persons subject to 7 <br /> WORKERS'COMPENSATION Laws of California." <br /> THE:APPLICANT MUST gtILjLA8,WgRKING HRS IN„ADVANCS FOR ALLY REQUIRED INSPECTIONS. <br /> Signed x Title Date <br /> I <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED: <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Issued Area <br /> Grout.Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: € <br /> I <br /> ACCOUNTING ONLY: AID# <br /> ,CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> i <br /> C-57 I CENSED,CONTRACTOR MUST SIGN=IXENSE&WORKE1tS'4COMPENSATION DECLARATION <br /> UNIT IV-6/23/99/sign bkpg/MI _ - - . .._._ _._ _ <br /> f <br /> R <br />