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0 <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES QFi� Co- KGI� <br /> ENVIRONMENTAL HEALTH DIVISION ("PHS-EHD") ✓ <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3450 <br /> FU MPT <br /> ,vl NON-REFUNDABLE PERMrf EXPIRES 1 YEAR FROM DATE ISSUED <br /> 4pplicabon 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 <br /> '941115.3 and the Standards/off San Joaquin County Public Health Services, Environmental Health Division. <br /> QQ (�f BEry hp e ,f gsi6i.ttc' dy . Zip�AarceW,Assessor's <br /> WEi L Location 1 !? r �f Cross Street �C" 707 Parcel# r' <br /> ?ROPERTY Owner �Tooa a 1t � Address ,LCity Lp Phone# G" <br /> C-�Contractor Q '^yLn�.,V Address �a.-�I�r [e1a.n 7D, City Jt�°��^+ Zip? <br /> Consultant/Sub Conrractor k FF,4Pur:nu e.-En'�/, Address/9w PPomeWS- /7-&City ui� Lit ja/L�Phonei&/O)6-57-,kaa0 <br /> GIS Coordinates:X Y ,Township Range Section <br /> WORK TO BE PERFORMED <br /> J'NEW WE—' /BORING(CPT, GEOPROBE,HYDROPUNCH, HAND-AUGER OTHER-) D DESTRUCTION(choose type below) <br /> 0 SOIL BORING# DOVER-BORE <br /> ZWEL# .SYiF-O/3 0PRESSURE GROIT <br /> -Other. <br /> COMMENTS: <br /> TYPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 <br /> MONITORINGHOLLOWSTBJ DIA OF BOREHOL_' /A' " MULTIPLE CASINGS?0 YES fZNO WELL CASING DIA: Y / <br /> 0 =,-TRACTION D AIR HAMMERJDRIVEN CASING THICKNES </o TYPE OF CASING: 0 S EEL VPVC 0 OTHER: <br /> VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 6( 7REMIE TYPE TO BE USED: DAUGERS HOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: EYes 0 No (NOTE: MAXIMUM FREES-FALL DEPTH IS 3C', <br /> t'. SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH 1-46 , JVBOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER: CONDUCTOR CASING PROPOSED? A) (ff 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 anc that the work will be done in accordance with San Joaquin County Ordinances, Stare Laws.and Rules <br /> and Regulations 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 Pamir is issued,1 shall not employ persons subject to WORKMAN'S COMPENSATION Laws of CalHomia." Contractor's hiring or sub- <br /> contracting signature certifies the following:'I certify that in the performance of the Www for which this permit is issued.1 snail employ persons subject to <br /> VVORKMAMS COMPENSATION Laws of Cafifomfa.- —" <br /> THE <br /> APPLICANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Sicnedx 1�/I? I��/ 2�e4oT4hos/ Trle.lie 'PrJ�th[an. Date 6/i7/g <br /> Q,�y /rwrF,t� <br /> SEE SITE MAP IN UNIT IV WORK PLAN. DATED /// <br /> DEPARTMENT USE ONLY Area✓ <br /> Application Accepted By Date Issued b / <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By .n Date <br /> MMENTC I CONDITIONS: <br /> FAC# <br /> ACCOUNTING ONLY: AID: I <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH I RECEIVED BY DATE PERMITfSERVICE REQUEST NUMBER INVOICE <br /> SR# D <br /> V N'i T T_V-5/99/M: <br />