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WELL PERMIT APPLICATION FORM UNIT IV <br /> SAt4 JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION ("PHS-EHD") <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 30 <br /> (209) 468-3450 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> .kpplication 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 4-1115.3 and the Standards of San Joaquin County Public Health Services, EnvironmentalAssessors Health Division. <br /> 5 �t(,4LA c-4L�r }��,._lJ,�c,c Cross Street City � Zip �� PaQrncel» <br /> L L tion (/01 �� / /lI� efi` <br /> ddreS 4 �✓��G<<}p�«c.4.d` ��i ��cc Phone» <br /> PROPERTY Owner / Gr�r�� T�6>— <br /> C-57 Contractor e� /I Address�_0��� City�,o/l si7�Zipl��-Lic#)2046JPhone»707 VW-1 KK <br /> Address2�g7GS�/ City/ ' Li _Phon (A2ff <br /> Consultant/Sub Contractor - <br /> 3t5 Coordinates:X <br /> Y Township Range Section <br /> WORK TO BE PERFORMED <br /> 0 NEW WELL/BORING(CPT.GEOPROBE.HYDROPUNCH,HAND-AUGER.OTHER`) DESTRUCTION (choose type below)�OVER-BORE <br /> WE <br /> 0 L BORING» PRESSURE GROU <br /> O WELL <br /> 'Other. <br /> COMMENTS: <br /> -'SPG OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br /> O MONITORING O HOLLOW S7EM DIA.OF BOREHOLE/'ALO MUL'IPLE CASINGS?Q YES $-NO WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/ORIVEN CASING THICKNESS TYPE OF CASING: O STEEL 0 PVC 0 OTHER: <br /> VAPOR MUD ROTARY DEPTH OF GROUT SEA: T REMIE TYPE TO BE USED: 0 AUGERS OHCS= <br /> 0 AiR SPARGE PUSH POINT GROUT SEAL PUMPED: O Yes 0 No (NOTE: MAXIMUM FREE-FALL DE IS 30'} <br /> SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 ST = <br /> 0 OTHER: CONDUCTOR CASING PROPOSED (if YES. list specifications here <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS! <br /> i hereby certify that I have prepared this application and that the worn will be done in accorcance with San Joaquin County Ordinances.State Land Ruies <br /> and Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: "I certify that in the performancwe work <br /> for which this permit is issued,I shall not employ persons subject to WORKMAN'S COMPENSATION Laws of California." Contractors hiring or sub- <br /> contracting signature certifies the following: "1 certify that,n ire performance of the work for wnrC.`J"his pe.—mits ssu.,ed. I shall employ persons subject is <br /> WORKMAN'S COMPENSATION Laws of California.' <br /> 4TAPPLICANT MUST CALL 48 HRS IN ADVANCE FOR ALL <br /> REQUIRED INSPECTIONS. <br /> Title C.*4-S6" _Date —��— <br /> Signed <br /> SEE SITE MAP I UNIT IV WORK PLAN. DATED C-.z F - 1 <br /> DEPARTMENT USE ONLY —��_I r �� <br /> Application Accepted By <br /> Date Issued I Area <br /> Grout Inspection By Date <br /> Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> FAC» <br /> ACCOUNTING ONLY: AID# <br /> �i PE CODES FEE INFO AMOUNT REMITTED CHECK#ICASH I RECEIVED BY DATE PERM <br /> ITISERVICE REQUEST NUMBER I INVOICE <br /> 9. <br /> oo <br /> UNIT IV-5/99/MI <br />