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WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ' „ <br /> ENVIRONMENTAL HEALTH DIVISION ("PHS-EMD") <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3450 <br /> i <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> .aeotiwtion is hereby nude to San Joaquin County for a Permit to mns,,er andlor install me work described. This application is made in mmoliance with <br /> San Joaquin County Devetooment Tido.Chapter 9-1115.3 anti the Standards of San Joaquin County Public Health Servrczs.Emmvnmental Heath Division. <br /> / p�j CI) Assessors <br /> WELL Location 1]f 0L1 S , 14Cr f IL'iA, /S . Onus Sheet CAy Z� PiKela 1 / <br /> PROPERTY Owner lGclS `';DV�r-t�YAtldfC35 tti 1.r+() F{s.t(Lwi Crty �P�C3�D PnonNe <br /> C.57 contractor 'V it f ij bC i It I l n yr L-o Addr"s?n .V>Jx S 1 C:tY L . t 5 - ZD2Y S71 U&7lZ5 y Phone#jil <br /> OOnsutart I Sub Conttractor,]jLICYi j0Jf. Address t3't lJ TirS+i vtS X13 Oily�VS�'t u. t.iCt vnone=(7l`{�I';3f.-b 6*3 Z.. <br /> 315 Coordinates:X Y .Towns" Range - Section <br /> WORK TO BE PERFORMED <br /> EWWELL I BORING(CPT,GEOPROBE HYDROPUNCH,RANO-AUGER.OTHER') p DESTRUCTION(cheese type betowi <br /> Q SOIL BORIp PRESSURE GROUT <br /> NG r p OVER-BORE <br /> WELL e 5 i k <br /> 'Other. <br /> :OMMENTS' <br /> ryPE OF WELL CONSTRUCTION TYPE CONSTRUE-noWSOECIFICATlONS <br /> Y�MONITORING �HOLLOW STEM Dtk OF 3OREHOLE MULTIPLE CASINGS?p YES Q NO WEL' <br /> CASING DIA:Z r/ <br /> Q EXTRACTION Q AIR HAMMERfORWEN CASING THICKNESS TYPE OF CASING: Q STEEL Q PVC p OTHER: <br /> ]vAPOR - Q MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED 0 AUGERS pHCSE <br /> a AIR SPARGE p PUSH.POINT GROVT SEAL PUMPED: p Yet p NO (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING a RANO AUGER APPROX.BORING DEPTH p BOLTED TRAFFIC BOX or p STOVE PIPE <br /> OTH-eR <br /> CONDUCT OR CASING PROPOSED? (if YES.list 5xzdicatrons here). <br /> _ I <br /> OCMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS! j <br /> .hereby certity that I na„e preoamo tis appkatiort and that the.vont wia be done in acantUnde with San Joaquin County Ordinances.State Laws.and Ruies <br /> and Regulations of the San Joaquin County. Homeowner or licensed agent's signature Certifies tate following: 'I certify that in the performance Of the work <br /> .'or which this permit is issued.I shelf not employ persons subjed to WORKMAMS COMPENSATION Laws of Caldlomia.” Comra fors hiring W sutr <br /> :pntgRinp signature certifies Iowmq¢T Certify Char in the performance of Pte work for wrnM this Permit is issued 1 snail emPby persons suo{94T to <br /> iYORK.MANS COM PON Laws of <br /> T E APPLICA PMT CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> P <br /> Signed nve t Vi,c t I gi.2 Date�.I ej ct <br /> SEE SITE MAP IN UNIT IV WORK PLAN. DATED Oc><. /_9 1?24 <br /> /nDEPARTMENT USE ONLY f <br /> ACplicbtibn Accepted By (0—Atd0 Date Issued / - ZO —0 0 Arca 0 7 S(v <br /> Grow Inspection S Date Fuel lnsoeaion By Date <br /> Oeswtamn Iniu eche Date } <br /> COMMENT (CONDITIONS: a A.0 ✓rI(aJS df.J '�T r++0 �4. 4.�T N^. TI'C. <br /> Wvf'G el.es�e."�" <br /> FACS <br /> ACCOUNTING ONLY' AIDa { <br /> I <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKaICASH RECEIVED BY 1 DATE PERMITfSEitVICE REQUEST NUMBER INVOICE <br /> e�-o SLo CID V14101 SR# 0 0-;t- 1 7 if ' <br />