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so � V ' FILE UPI <br /> WELL PERMIT APPLICATION FOR VV& IT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVIC 5,- <br /> ENVIRONMENTAL HEALTH DIVISION PHS-EHD L' ;: �:'� i'> <br /> ( ) L L I_ <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 Q'j- ")-, <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED F��1j'�?(41 J is"`! I-1_./1 I.i.1. <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This applicatjpr pma'(�e jn orrf {i'a'rrc�e with <br /> San Joaquin County Dev lopment Title, C"ha ),, 9-1115.3 and the Standards of San Joaquin County Public Health Service's, Er1Vub men}til. le2ftR Division. <br /> �, �i y�f1 1I qr� Assessor's <br /> WELL Locations - t�/l�A- Cross Street r(,e,'�f City \�•i`�l _Zip 1 J Parcel# �,2p - 0'0/ � <br /> PROPERTY Owner t \�r9t�_� (� Address�3�z��e"/7��� \��^;�� rCity�t¢` ,40 � ip '�.3 Phone#�s/ -95(-SU2— <br /> C-57ContractorV �rt`y�. Address?,09 �.7r�c <to City \GZipLic# 2� hone# b�0�j <br /> Ccnsultan Sub Contractor �C(V(.t.C,�:> � Address 6,al,�,�s ` l \City Lic# PInone#o20 -4W-76�( <br /> GIS CQordinates:*4T5g6,�',YZM341-10' ,Township Range Section <br /> WORK TO BE PERFORMED <br /> \�]NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER") 0 DESTRUCTION(choose type below) <br /> 0 SOIL BORING# � „ 0 OVER-BORE <br /> \4]WELL# �2- 3 0 PRESSURE GROUT <br /> 'Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS f <br /> ---{j MONITORING HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?Q YES ?kNO WELL CASING DIA: �- <br /> 0 EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS SC�.� TYPE OF CASING: Q STEEL APVC Q OTHER: <br /> Q VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL C f TREMIE TYPE TO BE USED: AUGERS QHOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: VYes Q No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER APPROX.BORING DEPTH vZO � 30 Q BOLTED TRAFFIC BOX or 9STOVE PIPE <br /> 0 OTHER:_0 OTHER CONDUCTOR CASING PROPOSED? N v (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:"l 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 /> CALL THE UNIT—W INSPECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed x _ Title/CompanytV <br /> Print Name , <br /> _- <br /> ` 1 x 1N UNIAx �ate a 3� <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Issuedffqpm <br /> rea <br /> Grout Inspection By N Date ti n Final Inspection By at <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> FArjf <br /> PE CODES FEE INFO AMOUNT REMITTED HECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> d U \ '<1 at <br />