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WELL`eERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES r <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 /> 't IJ- <br /> NI Assessor's <br /> WELL Location�4Vi4- - I&7�/ 9f Cross Street AAs✓/" City Zip Parcel# <br /> PROPERTY Owner t�ggf 1 69Z' Address City 7Zip Phone# �i/y <br /> C-57 Contractor C �Q� /Jrl rJ Address Of.?, OMCZ- elole& - �C,iitty��-g4 Zip9'���"Lic# 1 /� Phone G �//r v` <br /> Consultant/Sub Contractor AIV Address �W k��GX� /City Lic# Phone# "ddb <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED <br /> NEW WELL/BORING(CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER,OTHER') 0 DESTRUCTION(choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE <br /> WELL# &97 , • 2 /1r( 0 PRESSURE GROUT <br /> 'Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING HOLLOW STEM DIA. OF BOREHOLE f4/ MULTIPLE CASINGS?0 YES WNO WELL CASING DIA: Z <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS 5;4f L/Q YPE OF CASING: 0 STEEL x PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 7 ?) TREMIE TYPE TO BE USED: 0 AUGERS OHOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: WYes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER:_0 OTHER CONDUCTOR CASING PROPOSED? (if YES, list specifications here): —411 <br /> COMMENTS: le <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENVS INMMITS <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'COVPENSA TION 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 /> WORKERS'COMPENSATION Laws of California." <br /> CA THE U INSPEC OR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. �Q / <br /> Signed x Title/Companyy 7- Ao-414-mee-W t7�OGNtIl�t9i?/LtQI(�sT, lit. <br /> Print Name /"l CC✓ Date <br /> SEE SITE MAP IfIN UNIT IV WORK PLAN DATED: <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Issued Ti a Area <br /> Grout Inspection By 1_:� Date z, v v Final Inspection By, Date�,_'CJ <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> so ( 4SC, t 3IE i9 C 6 Z cnSR# 003 Zo6 <br /> 1/18/2000 <br />