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WELL PERMIT APPLICATION IRM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <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,Environ a mental sHealth Division. <br /> WELL Location L-I IV, V7d o uu rp trl Cross Street Fv­mw ) City f T ocK l b t l Zip 10,61- Parcel# <br /> PROPERTY Owner Aul'o 4�ti✓-5%Aati/ $ Address ahGb f-ha" Lwn D/_City 5t-44to" Zipg5' 'Il Phone# 473 " $900 <br /> V,+K r,41 <br /> C-57 Contractor Ad✓ouc2i (i=o F'k✓1+4ddress W065 1/. Nr, Ifrh W'gy CRy S)�Zip 43F04 Lic#640}y'rPhone# x{67 1606 <br /> Consultant/Sub Contractor Address City Lic# Phone# <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED <br /> 0 NEW WELL/BORING(CPT,GEOPROBE, HYDRPUNCH,HA[JD.AUGER,OTHER*) p DESTRUCTION(choose type below) <br /> 4ECSOIL BORING# L (71 0 OVER-BORE <br /> 0 WELL# PRESSURE GROUT <br /> *Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING O HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?O YES 0 NO WELL CASING DIA:_ <br /> O EXTRACTION O AIR HAMMER/DRIVEN CASING THICKNESS _ TYPE OF CASING: O STEEL 0 PVC 0 OTHER: <br /> O VAPOR O MUD ROTARY DEPTH OF GROUT SEAL T- D. TREMIE TYPE TO BE USED: O AUGERS OHOSE <br /> 0 AIR SPARGE H PUSH POINT GROUT SEAL PUMPED: p Yes Q,No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> %SOIL BORING O HAND AUGER APPROX.BORING DEPTH 20 O BOLTED TRAFFIC BOX or O STOVE PIPE <br /> O OTHER:_O OTHER CONDUCTOR CASING PROPOSED? (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 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 California." <br /> 7 <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HRS IN ADVANCE FOR <br /> PALL REQUIRED INSPECTIONS. <br /> Signed x /lt3V "r1K7 �""r't _Title/Company AdVVO( V Q^ rKN1rol 041-t 14 <br /> Print Name 15tv7n n�f`rbl'''rh Date 6I `7S-00 <br /> SEESITE MAP IN UNIT IV ,WORK PLAN DATED: <br /> DEPARTMENT USE ONLY <br /> Application Accepted By .r (sdxA Date Issued Area <br /> Grout Inspection By - Date 2 Final Inspection By Date <br /> Destruction Inspection By Data <br /> COMMENTS/CONDITIONS: d, S OF r S N - <br /> 5 -�= t ` n! aeber r -sre <br /> ACCOUNTING ONLY: ;iiL <br /> PE CODES FEE INFO REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 2 U ! 2 7� 06Z (`� <br /> )/)8/2000 <br />