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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., 95202 <br /> (209) 458-3449 <br /> NON-REFUNDABLE PER�ti11T EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct andior 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 Oivision. <br /> A 952,42_ Assesso(s <br /> WELL Location 2soo W � vt• Cross Street ff5-- Cay i Zip �ParcetT <br /> n �j i <br /> PROPERTY Ow`ne11r ' <br /> o Address +(7• SJR Q�-��� City i Zip7SPhone- <br /> C-57 Contractor <br /> yUP n x bf�; Inr,Address p �vo Ci 5q rr, u2ipQSb9[ Lic'*5I Phonemgj�"3�3-�_��� <br /> -- 33 #55001 i �! LIG',# Phone�5.3p-�7b_-fez <br /> Consultant!Sub Contractor� r4�►5 - („Address (e <br /> Y Township Range Section <br /> GIS Coordinates;X , <br /> W❑RK TQ BE PERFORMED <br /> a pESTRUCTION(choose type belc,v) <br /> )<NcW WELL/BORING(CPT,GEOPROEE, HYDROPUNCH, HAND-AUGER,OTHER") OVER-SORE <br /> 0 SOIL BIER NG PRESSURE GROUT <br /> yV1=LL 0 "► 1 b <br /> 'Other: <br /> COMMENTS: <br /> TYPE OF w>=Lt_ INSTALLATION TYPE CONSTRUCTION SPECIFICATrCNS <br /> ti10N470r^tNGHOLLOW STE�IM DIA- OF BOREHOLE _tv1ULT1PLE CASINGS?Q YES p NO WELL CASrNG OIA�+N <br /> Iq rr TYPE OF CASING: 0 STEEL `kFVC U OTHEP,: <br /> (3 EXTRACTION a AIR HAMM1�ER10RiVEN CASING THICKNESS � �, <br /> [}VAPOR 0 M� jo ROTARY DEPTH OF GROUT SEAL -iREMIE TYPE TO 5E USSD: {t AUG=RS SOS= <br /> p4R SPARGE 17 PUSH POINT GROUT SEAL PUMPED: es 0 No (NOTE: MAXIMUM FREE-FALL DEPTH 1S 30') <br /> HAND AUGER APF ROX• SORING DET{H OLTEO TRAFFIC BOX or U STOVE PIPE <br /> TI SOIL BORING 0 if YES,lists ecifications here), <br /> p OTHER_ [j OTHER CONDUCTOR CASING PROPOSED. t p- <br /> CCMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> , ,hereby certify GSat I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,State La-tis, and Rule <br /> Homeowner of licensed t's signature <br /> and Regulations <br /> ss ermit is 7ssuedJoaquin <br /> f shelf net employ person subject tonWORi{RRS CO•fyfP1=Nfy that In the performance Ofthe wcr� <br /> SATION Laws of C�alwornia." cont acctor's hi ng or sub- <br /> for which P <br /> contracting signature certifies the following: "1 certify that in the per`orrnance oftYre work fOrwhiCh this permit is issued, !Shelf employ persons su1'lect to <br /> WORKERS'CppdpENSA rlON Laws of California.” <br /> CALL THE NIT IV INSPECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> p *44. <br /> t r-ti TltlelGompany <br /> dx <br /> Sean ��' Ft ffi -Date �0� <br /> CCaS Icy;MAF IN ,USi'FE LANm APrint Narne :,� <br /> DEPARTMENT USE ONLY <br /> Date Issued L?U Lop <br /> Area <br /> Application A=pled By Date Final Inspection By Date�� <br /> Grout Inspection I3y <br /> Date <br /> Destruction{nspectian 6y , <br /> COMMENTS!CONDITIONS: w ` <br /> ACCOUNTING ONLY: AID# <br /> PSC CODES 1 EE INFC7 AMOUNT REMITTED CHECK REC'.D BY' OATS= PERMIT 1 SERVICE REQUEST� INVCICE <br /> SSBI y o0 4 72-Z,& 1 <br /> : <br /> 1./18/2000 <br />