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WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUtN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION ("PHS-EHD") ; <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3450 <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, Environmental Health Division. <br /> l `` Assassor•s <br /> ''n•© <br /> WELL Locatlon <br /> 1Ut3q� Q,lc1�.1� L41WQ- Cross Street *k��1hSA-City_LQ1K:1 Zip Parcel# <br /> P- L 2.ORck _Cay �l h Zip7723'2. Prncnel(5 Sq S- 3a6 <br /> PROPERTY OwnerGR.t►.11D��h_JL�` 1 � Address ADX <br /> C•57 Contractor cy% Dy;\k,\ Address <br /> °150 Wv­ CityMpk�iwe-Z Zip"n.3 Lic#93SI0 Phone#C12s)3(3 -Spd0 <br /> Consultant Sub Contractor <br /> Address <br /> P�!"kinS Sr City Soho"IG, Licrt Phone�7o7)g3S-Lj450 <br /> GIS Coordinates:X <br /> Y Township Range Section <br /> WORK TO BE PERFORMED <br /> DESTRUCTION(choose type below) <br /> tJEW WELL 1 BORING(CPT, GEOPR06E. HYDROPUNCH. DESTRU <br /> HAND AUGER,OTHER") 0 OVER-BORE <br /> a SOIL BCRtNG# 0 PRESSURE GROUT <br /> p WELL#MW 66— ; <br /> •Other: <br /> Co�.IMENTS: r t <br /> TYPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br /> �, CNITORING VCLLOW STEM DIA.OF BOREHOLE Id t� MULTIPLE CASINGS?0 YE5 O WELL CASING 01A: 4 <br /> EXTRACTION AIR HAMMERIDRlVEN CASING THICKNESS Sr�.40 TYPE OF CASING: 0 STEEL 'XPVC O OTHER• HOSE <br /> 0 VAPOR MUD ROTARY DEPTH OF GROUT SEAL.^' Sar T+REMIE TYPE TO BE USED: Q AUGERS 0 <br /> 0 AAP SPARGE 0 PUSH POINT GROUT SEAL PUMPED: Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> HANG AUGER APPROX, BORING OEPTH ^' BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 1?SOIL BORING Q CONDUCTOR CASING PROPOSED? it YES, fist specifications here): <br /> OTHER: <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS! <br /> I hereby cartity that I have prepared this appllliameown®r or licensed <br /> agent'sdsignatuone in re certifiest hstfolSlowingan a l certify that quin County Ordinances.the <br /> Q rfvrmance of he work <br /> Sub- <br /> and Regulations of the San Joaquiny arsons subject to WORKMAN'S COMPENSATION Laws of Cs/iforrria." Contractor's hiring or sub- <br /> to <br /> forwhich this permit is issued,1 shah Trot employp 1 <br /> contracting signature certifies the following: '1 Certify'that in the performance of the work fru which this permit is issued.!shall employ persons supleci <br /> WORKMAN'S COMPENSATION Laws of Celifomia_" <br /> TH APPLIF,ANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Titles . E 1Date � 0 I 1 1 <br /> Signed x , <br /> SEE SITE MAP 1N UNIT IV WORK PLAN DATED 1011-3/60 <br /> DEPARTMENT USE ONLY Area Loi' <br /> ,,-Cale Issued <br /> Application Accepted By Oaten <br /> Oate 0 Finallnspection v <br /> Grout Inspection By Date <br /> Destructlon Inspection By l \ _ n, Nw <br /> COMMENTS/CONDITION <br /> v FACT <br /> ACCOUNTING ONLY: AIDiI <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKf!lCASH RECEIVED BY DATE PERMlT15ERVICE REQUEST NUMBER INVOIC <br /> no 5g# 602-LI 'l <br /> �Shc tom' - <br />