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�./ til►,_. <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN jOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION ("PHS-EHD") <br /> 304 E. Weber, Third Floor, Stockton, CA., 96202 <br /> (209) 46$-,3450 <br /> NON-REFUNDABLE PERMIT EXPIRES t 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 PuWic Health Services,Environmental Health Division. <br /> Assessors <br /> WELL Location <br /> 2D W- Ke�-TTLF-t- Nt-' L111• Cross Street_1*LT9H INS City L--t>I zip Parcel# OroO-02t7-(51 <br /> PROPERTY Owner (�REC-IOkY Tu-IERK0YAr4 Address 1S7 ekMoN.S CaNYot l Cay AL-A-t\AO Zip 91"07 Phones <br /> C-57 Contractor- ��i� `I)t2 t W N F Address o w D. City Hf�t l NE-Zip 94553 Licit485I65 Phone#(9 2,5-)313-58oa <br /> Consultanti Subcontractor *t8[L1A FN�1lRo1�1t�ET1�LAddress -ZZo IIS ST- City o o Lic# �A PhOner#L'f���935-g8�O <br /> G75 Coordinates:X <br /> Y Township Range Section <br /> WORK TO BE PERFORMED <br /> W<EW WELL I BORING(CPT. GEOPROSE. HYOROPUNCH.HAND-AUGER, OTHER") Q DESTRUCTION(choose type below) <br /> &-SOIL BORING# - ycA SB-Q p OVERBORE <br /> Q PRESSURE GROUP <br /> Q WELL 9 <br /> 'Other: <br /> C,IAMEN T S: <br /> TYPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br /> t] g ff MULTIPLE CASINGS?fl YES Q NO WELL CASING DIA; <br /> MONITORING SAOLLOW STEM DIA.OF BOREHOLE <br /> EXTRACTION p AIR HAMMERJORIVEN CASING THICKNESS TYPE OF CASING: G STEEL O PVC a OTHER: <br /> 9 VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO SE USED: f]AUGERS QHOSE <br /> Q AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: G Yes Q No (NOTE_ MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING Q HANG AUGER APPROX. BORING DEPTH -50' MAY_ BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> Q OTHER: CONDUCTOR CASING PROPOSED? (if YES, list specifications here); <br /> t <br /> COMMENTS: <br /> C <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS? <br /> I hereby cartify that 1 have prepared this appllcation and that the work will be done in accordance woth San Joaquin County Ordinances.State Laws, and Pulc <br /> and Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: "I cartify that in the performance of the wo <br /> for which this permit is issued,1 shall not employ persons subject to WORKMAN'S COMPENSATION Laws of Califomia." Contractor's hiring or si <br /> contracting signature certifies the following: 'I certify that in the performance of the work for which this permit is issued. I shall Amploy persons subject to <br /> WORKMAN'S COMPENSATION LawS Of CelifOmia_' <br /> THE PLICANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. p <br /> Title O E�Date 1� Z _[ <br /> Signed x <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED SEPTeMBER <br /> DEPARTMENT USE ONLY 41 <br /> Date Issued 1i 9 Arez <br /> Application Accepted By Da <br /> Grout Inspection By Qat Od Final Inspection By <br /> Destruction Inspection By Date <br /> COMMENTS J CONDITIONS: a acig AlVJ <br /> FACM <br /> ACCOUNTING ONLY: AID#777:�: <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKfUCASH RECEIVED BY DATE PERMIT/SERVICE REQI <br /> his.01 �� L 1�Z3 p0 Z! S7 <br />