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F WELL PERMIT APPLICATION FORM UNIT IV <br /> L U <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_PERMIT EXPIRES 4 YEAR FROM DATE ISSUED <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 /> Sart Joaquin County Development Title Chapter 9-1115 3 and the Standards of San Joaquin County Public Health Services Environmental Health Drvis= <br /> V7 E- /^ Assessors <br /> WELL Lacatian� C-'-1;""4' <br /> �'�i ant Cross Street_ `c,t'f,rv�t City_ -�' -k V-� Zrp rt`�Zy Z Parcel# t 31 ,2-4,) -0-0 <br /> PROPERTY Owner l���._1_ Ca.--1; rc, ' . --Address PC., 1, 7W0 *7 City r <br /> Zip y�'L� l Phone# le- -714 <br /> C 37 Contractor ��c�-eicc �y�ti,,y Address 3t,3z C �vcL ��rx City Zrp�S 7` 7-Ltc# 7+3-;WPhone{��f'- C jS <br /> - 5 4r c 1 2a Y� <br /> Consultant!Sub Contractor Cir t�-f z-- R,,r. 1�TAddress 3 �`� `��iL Gity Cnc�� Uc# 55-7 7 Phone#`i 1,. -C:;t f�� <br /> GIS Coordinates X_ Y Township Range Section <br /> WORK TO 13E PERFORMED <br /> 'ANEW WELL l BORING(CPT GEOPROBE HYDROPUNCH HAND-AUGER OTHER-) C1 DESTRUCTION (choose type below) <br /> Q SOIL BORING# t (i OVER-BORE <br /> ,AlNELL#_(Z? Z �. -3, ..7titi (}PRESSURE GROUT <br /> 'Other <br /> COMMENTS <br /> PE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ,dMONiTORING )q HOLLOW STEM DIA OF BOREHOLE '3 ry`d IL?"MULTIPLE CASINGS?g'1'E5�ANO WELL,CASING DIA!/� <br /> 1]EXTRACTION Q AIR HAMMERIORIVEN CASING THICKNESS In qO TYPE OF CASING 11 STEEL U;PVC g OTHER <br /> 'VAPOR g MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED 11 AUGERS -4WOSE <br /> , AIR SPARGE {1 PUSH POINT GROUT SEAL PUMPED M®Yes p No (NOTE MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING Q HAND AUGER APPROX BORING DEPTH Sea. L,.ekX=, WOLTE0 TRAFFIC BOX or I1 STOVE PIPE <br /> Q OTHER q OTHER CONDUCTOR CASING PROPOSED? (if YES list specifications here) <br /> COMMENTS 2- ma i `€l', Z 4-- �'e�� rc i.n U.<I k - 4 til <br /> 1 ' I i G #'-' [a "Z I..ewi(a^ 7IC.r% Z`40D Z v. <br /> NOTE' OFFSITE BOl4INGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby certify that I have prepared ttits application and that the work w4l be done in accordance with San Joaquin County Ordinances State Laws and Rule <br /> and Regulations of the San Joaquin County Homeowner or licensed agent s signature certifies the foitowing "1 certify that in the performance of the wor6 <br /> for which this permit is issued,I shaft not employ persons subject to WORKERS'COMPENSATION Laws of California" Contf0clOF 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 f shall employ persons subject to <br /> WORKERS COMPENSATION Laws of Cafrfomla <br /> T7rL,1CA'N'T'MUST CALL 48 WORKING HRS IN ADDVVANCE FfO�R ALL REQUIRED INSPECTIONS <br /> Signed x rTitle t �beL.� �1e-J?�rs� Date_ - _ (OL At> <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED <br /> DEPARTMENT USE ONLY + <br /> Application Accepted Byt � �f�r-t+"--4_ _ _ __ —Date Issued- �% r'�(+% t✓ Area <br /> Grout Inspection By Date Final Inspection By Date _-- <br /> Destruction Inspection By Date <br /> MCOMMENTS l CONDITIONS <br /> ACCOUNTING ONLY AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D 13Y DATLO PERMIT f SERVICE REQUEST* INVOICE <br /> 3's D h I 10a SR# o QZL43 <br />-----r--51-LICENSED CONTRACTOR MUST SIGN LICENSE &WORKERS' COMPENSATION DECLARATIC <br />