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A0141 UNIT IV <br /> WELL PERMIT APPLICATION FORM <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES =CC �I�CL} <br /> ENVIRONMENTAL HEALTH DIVISION (":PHS-EHD") <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 . FEB 1 g 2003 <br /> • (209) 468-3450 <br /> ENVIRORMENT HEALTH <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT�4RVI F <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made�n flan th <br /> San Joaquin County Oe�eiopment Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, EnvironmentalAssessors <br /> Health division. <br /> WELL Location .D ter Toss Street a�Z atYparcel# <br /> City Zip eg3 phone# Xne �7S 2 <br /> PROPERTY Owner �G Address <br /> lJ'� City�Zip gSc�fr_7 �c# Phone# &-�7�- <br /> C 57 Contractor Address= y� y ' l / <br /> dreysS`;0r/ � City?'++Ii�(Y 'L.-Lic# Phone# - G <br /> Consultant I Sub Contractor �dtt s <br /> Township Range Section <br /> GIS Coordinates:X <br /> Y <br /> t <br /> WOR!(TO BE PERFORMED <br /> DESTRUCTION(choose type below) <br /> q!NEW WELL.I BORING{CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER") OVER-BORE <br /> [] SOIL BORING# '-Z PRESSURE GROUT <br /> p WELL <br /> *Other: <br /> COMMENTS: <br /> TYPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br /> LE CASINGS?Q YES Q NO WELL CASING DIA: <br /> MONITORING Q HOLLOW STEM DIA. OF BOREHOLE MULTIP <br /> GIQi <br /> Q AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: ©STEEL 0 PVC Q OTHER: <br /> EXTRACTION <br /> 0 VAPOk MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: GAUGERS OHOSE <br /> AIR SPARGE 4 PUSH POINT GROUT SEAL PUMPED: 9 Yes (]No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> �] <br /> I <br /> n SOIL BORING D <br /> HAND AUGER APPROX. BORING DEPTH Q BOLTED TRAFFIC BOX or:Q STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications dere): <br /> OTHER: <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS-OR ENCROACHMENT PERMITSI <br /> nances late Laws. and Rules <br /> I!hereby certify that l have preparedJoaquin County. cation Homeowner or licenseat the dk will agentsdsignaEuone in ae <br /> certifies ehetfa owing�"I certify that inquin County lthe performance of the work <br /> and Regulations of the San Y <br /> for which this permit is issued,I shall not employ persons subject to WORKMAN'S COMPENSATION Laws of California." Contractor's hiring or sub- <br /> contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to <br /> WORKMAN'S COMPENSATION Laws of California.' � <br /> AP .LICANT MUST CALL 48 HRS IN ADVANCE FOR ALLR <br /> PE�UlRED INSPECTIONS. <br /> !' Title ate <br /> Signed 5 <br /> SEE SITE <br /> MAP UNIT IV WORK <br /> PLAN. DATED .2-10-03 2i5g�ck__� <br /> D PARTMENT USE ONLY / Area <br /> Date issued' / re <br /> ;Application Accepted By ate <br /> Date <br /> ,Grout Inspection By Final Inspection By <br /> iDestruction Inspection By Date <br /> ,COMMENTS l CONDI IONS: (/ V <br /> FAC# <br /> 1 ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REIUIITTED CHECK#! SH RE IV DATE PERMiT1SERVICE REQUEST NUMBER INVOICE <br /> co 1 <br /> slzl_s>rGr >•�c <br /> c sr��c�rrs�=cor� cxox� v�r�,�. , ..._ .z Rry_.•. � , . e.m. .�.� • <br /> UNIT-TV- 6/18/99/sign bkpg/MI <br />