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WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHSMEND) <br /> 304 E . Weber, Third Floor, Stockton , CA. , 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 'I 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 San <br /> Joaquin County Development <br /> �Till gL� ,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br /> 517 YKiS-( l \ Assessors <br /> WELL Location Cross Street �Ci�Zip7 Parcel# , Q <br /> PROPERTY Owne ,,`` f, Address ityZipl�'S,L�Q hone#�jt `r'1� 07 <br /> C-57 Contractor �W 1 � M Addres=� City �Zip Lic# — r ' r Ph on <br /> Consultant / Sub Conlracto Address 1J A tJV� CitK g1VA '" eL Phone# 7� r <br /> GIS Coordinates: X., y., Township Range Section <br /> WOR <br /> K TO BE PERFORMED <br /> EW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') 0 DESTRUCTION (choose type below) <br /> (L 0 SOIL BORING # p OVER-BORE <br /> D WELL # a PRESSURE GROUT <br /> 'Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING DLLOW STEM DIA. OF BOREHOLE AI MULTIPLE CASINGS? a YES a NO WELL CASING DIA: 2 yf <br /> TRACTION R HAMMER/DRIVEN CASING THICKNESS t� DZ--- TYPE OF CASING: a STEELeVC a OTHER: <br /> a VAPOR n MUD ROTARY DEPTH OF GROUT SEAL/.S + iT TREMIE TYPE TO BE USED: GERS aHOSE <br /> a AIR SPARGE a PUSH POINT GROUT SEAL PUMPED: 0 Yes 0io (NOTE : MAXIMUM FREE-FALL DEPTH IS 30') <br /> n SOIL BORING a HAND AUGER APPROX. BORING DEPTH�W ��F1OLTED TRAFFIC BOX or a STOVE PIPE <br /> n OTHER:.0 OTHER CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br /> COMMENTS: III Ili 11111111 1100t <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 <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: 01 certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to <br /> WORKERS' COMPENSATION Laws of California -� <br /> TNI= aPI� arrr usrca � ga ►otkra ► Irs , ! ? srNsPct <br /> Signed x Title _ Date <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED : 1 ZXe:' <br /> /7DEPARTMENT USE ONLY <br /> Application Accepted By� v Date Issued y' o' 0 ` &V Area 0 7 S (o <br /> Grout Inspection By tic-r�� Date �/ I' lD0 Final Inspection By Date <br /> Destruction Inspection By - - Date <br /> COMMENTS I CONDITIONS eac- 014) efl&G O Ia CAstcgrq <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK # RECO BY DATE PERMIT 1 SERVICE REQUEST # INVOICE <br /> C.57_LtCLSET7 ;GfbR 1GITS`E SIGN LE1�FS13 <br /> 3tS'.,f 01VI�EI�iSi�TT€? TE{ A1tAI()N <br /> UNIT IV - 6/23/99 /sign bkpg/MI - <br />