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WELL PERMIT APPLICATION rvRM 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 1 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 /> 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 /> WELL Location-1S Z K Cross Street PAI,% A,.e City S4rX 6&1 Zip Parce!: <br /> C"tra/ V4110y 4" ' <br /> PROPERTY OwnerMA_,QA1LI(-e a eIU ouliv Address/n 3'5 li ._L <br /> g. ,. how) #'3UL Cityyrj�it�ipn� Zip 95 7 Fhone#�SL�-9590 <br /> C-57 Contractor<r �AiVpI% Lj Address Z9i S44f;SPbftt City�Zip Lic„a� 6Phone# 772-.3570 <br /> Consultant/ b Contractora,.Mcf Z Addre_s.17/U)041,hf .5k City lux-I Lic# Phone# ?,fk71?fS/ <br /> GIS Coordinates:X 'Y Township F.ange Section <br /> WORK TO BE PERFORMED <br /> lEW WELL/BORING(CPT,GE PROBE, HYDROPUNCH, HAND-AUGER,OTHER) a DESTRUCTION (choose type below) <br /> OIL BORING# SB/ SBS_ 0 OVER-BORE <br /> 0 WELL# 0 PRESSURE GROUT <br /> "Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE IN I"MULTIPLE CASINGS? 0 YES ONO WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL O PVC 0 OTHER: <br /> 0 VAPOR 0 MU ROTARY DEPTH OF GROUT SEAL 3o + TREMIE TYPE TO BE USED: 0 AUGERS gKOSE <br /> WAII SrARGE USH POINT GROUT SEAL PUMPED: O Yes g10 (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> L BORING 0 HAND AUGER APPROX. BORING DEPTH �� kms'+ 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER:_0 OTHER CONDUCTOR CASING PROPOSED? I (if YES,list specifications here): <br /> COMMENTS:�i�j.U �6e i ` ;. r- S T� 1 :b2 .� bGList�J zlado <br /> SR 2 - S814 S' bebw etude <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,State Laws, and Rules <br /> and Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: "I certify that in the performance of the work <br /> for which this permit is issued,I shall not employ persons subject to WORKERS'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 /> WORK_RS'COiVPE"JSaT/ON Laws of Califo m ia." <br /> S. <br /> THE APPLICANT MUST CALL 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED IINS/PECTIO . <br /> Signed x Title ;2C"l CQ-1 '�S Date /// / 2-G60 <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED: <br /> DEPARTMENT USE ONLY c, <br /> Application Accepted ByL Lj r r''9�' Date Issued Jc / �G v v Area <br /> Grout Inspection By V 1 ✓ Date I Final Ins.ection ey Date <br /> Destruction Inspection By Date <br /> COM�NTrS/CONDITIONS: -,' / 'a 1_i i?1 <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT f SERVICE REQUEST# INVOICE <br /> C-57 LICENSED CONTRACTOR MUST SIGN LICEN E ORFERS' COMPENSATION DECLARATION <br /> UNIT IV-6/23/99/sign bkpg/MI <br />