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WELL PERMIT APPLICATION FORM UNIT IV <br /> i <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third door, 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 /> At <br /> Assessors <br /> WELL Location At i3o U' ,41der SI- Cross Street i�ctfn fave City 5 �1 Zlp Parcel# t7T-o5O' Oq <br /> PROPERTYOwner [1' s�� kor Address Ct �I1 City t c�v. Ztp g6bZ Phone#616-1?937- 8359 <br /> �-1 mk lardn� 2S7`f2Lrc# 7+-t SIO Phone#�ctl6� 638-1[6`3 <br /> � <br /> C-57 Contractor e IJrtI11n:!,.—Address 3632 0W--C- ckcc aty& r �¢ <br /> Consultant/Sub Contractor tt�-� a.� ��c Address1Lq �1.�[a..,�pri I70_City ,c1,.Lrc# SS 77 Phone#C`tfb 6St'13x0 <br /> GIS Coordinates X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> NEW WELL/BORING(CPT GEOPROBE HYOROPUNCH HAND-AUGER OTHER-) 0 DESTRUCTION(choose type below) <br /> Q SOIL BORING# a OVER-BORE <br /> WELL# w-l Q PRESSURE GROUT <br /> OJ*'Other <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS Z „ <br /> 4raMONITORING HOLLOW STEM DIA OF BOREHOLE 8 MULTIPLE CASINGS?a YES ON <br /> WELL CASING DIA <br /> Q EXTRACTION Q AIR HAMMERlDR1VEN CASING THICKNESS 51L,_ qO TYPE OF CASING 1]STEEL WVC (I OTHER <br /> a VAPOR p MUD ROTARY DEPTH OF GROUT SEAL 72, TREMIE TYPE TO BE USED 0 AUGERS tRHOSE <br /> a AIR SPARGE PUSH POINT GROUT SEAL PUMPED tj]�1fes [J No (NOTE. MAXIMUM FREE-FALL DEPTH IS 30 <br /> 0 SOIL BORING I1 HAND AUGER APPROX BORING DEPTH 90 ' BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> OTHER 0 OTHER CONDUCTOR CASING PROPOSED')_(d 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 and that the work will be done to accordance with San Joaquin County Ordinances State Laws and Ru <br /> and Regulations of the San Joaquin County Homeowner or licensed agent s signature certifies the following "t certify that In the performance of the wo <br /> for which this permit Is issued,I shaft not employ persons subject to WORKERS'COMPENSATION Laws of California" Contractors hiring or sub <br /> contracting signature certifies the following "I certify that to the performance of the work for which this permit is issued I shall employ persons subject to <br /> WORKERS COMPENSATION Laws of Caltfomta <br /> TH P CIT MUST CALL 48 WORKING HRS IN ADVANCE (FOR <br /> /^ALL <br /> (REQUIRED INSPECTIONS <br /> Signed x Title �f t GCS 12G`l S'_Date g 1 <br /> 9 <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED. -2 c o� <br /> rDEPARTMENT USE ONLY <br /> Application Accepted BN Date Issued <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS <br /> FAACCOUNTING ONLY AID# <br /> CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 50 hk tk) d05 5 ►° c�I1 SR# O <br /> C-57 LICENSED CONTRACTOR MUST SIGN LIC SE &WORKERS' COMPENSATION DECLARATTO <br /> I",ITTTAI-A 121/00 /e,nn hksa/ML <br />