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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) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> ppiication is hereby made to San Joaquin County for a permit to construct andlor 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 /> Assessors <br /> WELL L Cation ? ir�Z: Cross Street Ls�lsr r"+c�� City S�oc{��_n Zip 115 Z02 <br /> PROPERTY Owner Ct 3 V !3�2gj< k,.,_Address ql4 N CC p,3: �, slit,`} Crty 5v,,I. _ Phone#20`1- ``f 3 r- 3-/C <br /> C-67 Contractor Ltic�_CL- t✓F`t I'li1oi. Address 3L3? _Lh�i �_t�1� _City ( �rx bv� Zip 9-17112trc#717510 Phone# q t&-3-S—11Gr( <br /> S � L[, <br /> Consultant Sub Contractor - - Address 3m-( 6, 1 C,-,l_�.�i _ City l rr,_4w� �Lse# ;,37-7 Phone# <br /> GIS Coordinates X Y Township Flange Section <br /> WORK TO BE PERFORMED <br /> ` NEW WELL I BORING(CPT GEOPROBE HYDROPUNCH HAND AUGER OTHER-) Q DESTRUCTION(choose type be)ow) <br /> ❑SOIL BORING# [I OVER-BORE <br /> fUWELL# L ) -I--C _-her x tom.LJ- 2 Q PRESSURE GROUT <br /> `Other <br /> ,QWMENTS <br /> IM OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING CKHOLLOW STEM DIA OF BOREHOLE 3 MULTIPLE CASINGS?D YES aNO WELL CASING DiA � r <br /> []EXTRACTION [I AIR HAMMERIORIVEN CASING THICKNESS 5,t,140 TYPE OF CASING IZ STEEL &DVC n OTHER, <br /> a VAPOR (I MUD ROTARY DEPTH OF GROUT SEAL 2L4 101- TRIEMIE TYPE TO BE USED (]AUGERS NWOSE <br /> AIR SPARGE o PUSH POINT GROUT SEAL PUMPED RYes p No (NOTE- MAXIMUM FREE-FALL. DEPTH IS 30') <br /> 0 SOIL BORING D HAND AUGER APPROX BORING DEPTH 7;` Q 120'` _11OLTEO TRAFFIC BOX or J]STOVE PIPE <br /> 0 OTHER 0 OTHER r CONDUCTOR CASING PROPOSED (if YES list specifications here) /� <br /> COMMENTS E7 Cd5 k c- C4 UJ[7r IS jJU`/3-1J C[. ^u[� SAY ' f JY�! 7�� _3J F�l�31 e" �4 <br /> = 5'� U L1`�G'IsCi <br /> NOTE: OFF 81TE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby certify that t have prepared this application and that the work will be done m accordance with San Joaquin County Ordinances State Laws ants Rules <br /> and Regulations of the San Joaquin County Homeowner or licensed agent s signature cerMsses the following "I certify that in the performance of the work <br /> for which this permit is issued,f shall not employ persons subject to WORKERS'COMPENSATION Laws of California" Contractors hiring or sub- <br /> contracting signature certifies the foitowing 'I certify that in the performance of the work far which this permit is issued i shall employ persons subject to <br /> WORKERS COMPENSATION Laws of Calstomra - <br /> T P L,TNT MUST CALL 48 WORKING HRS 1N ADVANCE <br /> F} FOR ALL REQUIRED INSPECTIONS. <br /> Signed x Title SJ11� Gr c 4 Date^ !U_e r <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED. <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Dot~ F,,,, ti Date Issued )CL ���• � �L _____Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> OMMENTS f CONDITIONS <br /> ACCOUNTING ONLY AID# FAr# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D 8Y DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 3 S O! ,�? =' t3 z Cats -, to 0 vc' 56# OL'QL4 <br /> =rTn r.-.�r"rTt A rTOR MUST SIGN LICENSE &WORKERS' COMPENSATION DECLARATION <br />