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WELL PERMIT APPLICATIONF! AM <br /> UNIT IV .- <br /> SAID JOAQUIN COUNTY PUBLIC HEALTH SERVICES _ <br /> ENVIRONMENTAL HEALTH DIVISION ("PHS-EHD",) <br /> 304 E. Weber, Third Floor, Stockton, CA., 952421 i'��! 52 <br /> (209) 468-3460 ,,. <br /> NON.REFUNDABL PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 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 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 /> Assessor's <br /> R Ani ..k 7,. _ T Cross StrewCity Zips / Parcel# <br /> WELL Location 's p <br /> PROPERTY Owner Address Ci Lp�phone# �f Z�_�iZar= <br /> C•S7 Contractor Address V � ''7� �G --'- CiU�-Zip Uc# Phone# <br /> City,&Ac/ i <br /> Consultant 1 Sub Contractor `� <br /> Address ;w _ Phone# <br /> `Sectioii :- tz= _ <br /> GIS Coordinates:X Y Torvnshep <br /> WORK Ti 8E PERFORMED �,,: <br /> DESTRUCTION(choose type below) <br /> EW <br /> WELL 1 BORING (CPT,GEOPRO$E, HYDROPUNCH,I tAND-AUGER.OTHER')" Q a OVER-BORE <br /> �+SOIL BORING# PRESSURE GROUT <br /> LL# ' <br /> ,Other: <br /> COMMENTS: <br /> YPI OF WELL CONSTRUCTION TYPE CONSTRUCTIQN SPECIFICATIONS <br /> MONITORING �iOL:.OW STEM DIA.OF BOREHOLE �' �i <br /> MULTIPLE CASINGS? YES ONO WELL CASING DIA:,Z <br /> a ! <br /> VC OTHER: <br /> Q EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS <br /> TYPE= OF CASING: Q STEEL ,lam Q <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL'S r-�t�c �_TREMIE TYPE TO BE USED' �AUGERS �FiOSE <br /> 0 AiR SPARGE Q PUSH POINT GROUT SEAL PUMPED:A'Yes tI No (NOTE: MAXIMUM FREE-FALL. DEPTH IS 30') <br /> Q SOIL BORING ,.a HAND AUGER APPROX. BORING DEPTH 2r � _ BOLTED TRAFFIC BOX or 9 STOVE PIPE <br /> OTHER: ' -' CONDUCTOR CASING PROPOSED? 4 (if YES.list specifications here): <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITSI <br /> I hereby certify that I have prepared this application and that the work will be done in sccordan a with San JOaqu)n County Ordinances,State Laws,and Runes <br /> and Reguiativtts of the San Joaquin County. Homeowner or licensed agent's signature Certifies the following: "1 certify that in the performance of the work <br /> for which this permit S Issued,1$1,811 nor employ persons subject to WORKMAN'S COMPENSATION Laws of Cafifomia." Contractors s hiring eCr o sub- <br /> for <br /> _-_contracting signature certifies the following: l:r e1Vfy that In tthe parformence of the worK for wniC1,:his permit is issued. !s1ra11 empfoy PO=ns <br /> ACRKMAArS COMPENSATION Laws'of CalifarN4.•,� ._ ` :.`:r`"" �"'"" �"` • '"'—� <br /> P ICA T MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS' ..r <br /> Signed x Title w� Date <br /> SEE SITE MAP IN UNIT .'IV WORK PLAN. DATED-11— <br /> DEPARTMENT <br /> ATED DEPARTMENT USE ONLY <br /> Date Issued Z Area, <br /> Grant InspectionApplicationation Accepted By . � Date.�— Date Final inspection By By <br /> Oestruction Inspection By Date <br /> -OMMFNTS I CONDITIONS: <br /> FAC# <br /> i ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RITC WED BY DATE PERMITISERViCE REQUEST NUMBER INVOICE <br /> I 35 ol q,00 2 i 2-� My 1 2 <br /> UNIT IV-5/99/MI <br />