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UNIT IV <br /> WELL PERMIT APPLICATION FORM ; <br /> SAN <br /> JOAQUIN COUNTY PUBLICHEALTH SERVICES <br /> , <br /> ENVIRONMENTAL HEALTH DIVISION ("PHS-EHD") <br /> 304 E. Weber;"ThA Floor, Stockton, CA., 95202 <br /> l <br /> i{209} 468-3450 <br /> II <br /> NON-REFUNDABLE PERMIT EXPIRES /:YEAR FROM DATEn 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 J',i <br /> San Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> lir M E Y f RYAssessor's <br /> WELL location H A IK 4 l N G WACross Street tir N City S t GGj, "T o t4 Zip 9 S10 1 Parcel# <br /> $AN JOAQVthI 'a i" '' r" ''i STWC TON Zi X15201 Phone# y66-62a'�� '� <br /> PROPERTY Owner CAI tA aL 1t; C METER Address''�DCity p <br /> <r(kIrCrrr � OW {O D 11 <br /> 1IlT+tir- 53 65E'to} 0 20 <br /> C-57 Contractor DitILLIRCr 4-T E WfirrAddress 9 5 0H' City Zip Lic# Phon # 3- '1 <br /> 5 6 t'C_ <br /> IkNCi+C it.G. E 11 <br /> Consultant/Sub Contractor 17,A M A Cr F- 1=Ny• Ad"dress a City I1V 9 t r_TA-Lic# 5 i? S 6 phone# 3 S91 ; <br /> y Township Range__ Section <br /> GIS Coordinates:X IS <br /> WORK TO BE PERFORMED s ° <br /> 1 NEW WELL!BORING(CP GEOPROBE,HYDROPUNCHi';HA'ND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> 1 SOIL BORING# C T-4 A : 6 fI OVER-BORE. N <br /> §'"'l''':'i i m Q PRESSURE GROUT <br /> WELL# <br /> 'Other , <br /> mri <br /> COMMENTS: = i <br /> TYPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br /> 'i F BOREHOLE 111 MULTIPLE CASINGS? YES p NO <br /> WELL CASING DIA: NA <br /> 5TE <br /> M DIA.O <br /> MONITORING HOLLOW <br /> Q EXTRACTION 0 AIR HAMMERIDRIVEN CASING THiCKNES5 N A TYPE OF CASING: STEEL Q PVC OTHER: N <br /> Q VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL T,;D^� 160 r 7REMtE TYPE TO BE USED: D,AUGERS CHOSE i <br /> AIR SPARGE PUSH POINT(C P C� GROUT S"EAL PUMPED: (]'',Yes R No (NOTE: MAXIMUM FREE-FA'Ltw DEPTH !S 30'? <br /> a '' `' I' BOLTED TRAFFIC BOX or D STOVE PIPE <br /> SOIL BORING p HAND AUGER APPRQX. BORING DEPTH j i d N A <br /> Q OTHER: CONDUCTOR CASING PROPOSED? N 0 (if YES,list specifications here): <br /> 1'I <br /> COMMENTS: , <br /> NOTE: OFFSITE BORINGS ...-QUIRE ACCESS OR ENCROACHMENT PERMITS! ]i <br /> work will be done in accordance with San Joaquin County Ordinances,State Laws,and Rules <br /> red this a lication and thatthe wo erformarWce of the work <br /> that I have prepared PP if that in the <br /> I hereby certify t R p .. <br /> and Regulations of the San Joaquin County. Homeowner oraicensed agent's signature certifies the following: "t certify P <br /> for which this permit is issued,t shall not employ persons.'subject to WORKMAN'S COMPENSATION taws of California." Goniractor's hiring or sub- <br /> contracting signature certifies the following: 'l certify that in th6perfoftance of the work for which this permit is issued, l sha!l employ persons'subject to I� <br /> WORKMA S C PENSA TION taws o!Cal1,om;a." ;� I !3 <br /> E APPLICANT MUST CAL �'`8'--HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS- <br /> Date <br /> i' Title `+ <br /> Signed R i I <br /> I SEE SITE MA IN UNIT iV�sIVII�ORK PL�>1tDAT ED <br /> DEPARTMENT USE ONLY <br /> Date Issued �DZ Area <br /> Application Accepted By Date. <br /> t O 1. Final Inspection By <br /> Grout Inspection By Dat p <br /> i <br /> Destruction Inspection By s !Date'� Ali <br /> COMMENTS I CONDITIONS: <br /> 1. FAC# i <br /> ACCOUNTING ONLY: AID# a ', <br /> s <br /> PERMITISERVICE <br /> PE CODES FEE INFO .AMOUNT REMITTED CHECFttr7CASH RECEIVED BY DATE" REQNUMBER INVOICE <br /> REQUEST <br /> I-b 02 <br /> Li <br /> t. 'UNIT TV-6/1/99/sign bkpg/MI J <br /> i <br />