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WELL PERMIT APPLICATION FORM UNIT IVP SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES f <br /> ENVIRONMENTAL HEALTH DIVISION ("PHS-EHD")!-j 1 : 03 <br /> 304 E. Weber, Third Floor, Stockton, Ck, 95202 <br /> (209) 468-3450 <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 -1 1 1 $, SAt3 TO A Q V I N ST. Cross Street kAtE LT00 City S To C k To N Zip95ZO3 Parcel# <br /> PROPERTYOwner HA1%IA0 F R`f Address P.O. BOX 5 ja _ ____City 1iA'WARD Zip 54543 Phone# (51c)'66-5000 <br /> C-57 Contractor V 4-W D R I LL I N CT Address F,0- 00 X 51 City Y t 5 TA Zip 94-Vt I Lic#17-0904 Phone# C}a1)314-19IS <br /> JkANCH,0 R-C-. <br /> -- <br /> Consultant/Sub Contractor R mA crl+ ENV. Address P-0, BOX 1069 CityMy Fl(A A Lic# 51656 Phone# (9I035 tt-3 250 <br /> GIS Coordinates.X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> a NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') I DESTRUCTION(choose type below) <br /> a SOIL BORING# a OVER-BORE <br /> a WELL# I PRESSURE GROUT <br /> 'Other: <br /> COMMENTS: 01=5T4k0'f 3 oN- SITC WE GLS Py V11C-SSWR E C-ROVr <br /> TYPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING a HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?Q YES a NO WELL CASING DIA: <br /> a EXTRACTION a AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: u STEEL p PVC o OTHER: <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: a AUGERS QHOSE <br /> a AIR SPARGE ©PUSH POINT GROUT SEAL PUMPED: a Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING a HAND AUGER APPROX.BORING DEPTH 11 BOLTED TRAFFIC BOX or a STOVE PIPE <br /> d OTHER: CONDUCTOR CASING PROPOSED? (if 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 in accordance with Sart Joaquin County Ordinances,State Laws, and Rules <br /> and Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: `7 certify that in the performance of the work <br /> for which this permit is issued,!shall not employ persons subject to WORKMAN'S COMPENSA]70N Laws of California." Contractor's hiring or sub- <br /> contracting signature certifies the following: 'k certify that in-the performance of the work'for which this permit is issued, i shall employ persons subject to <br /> WORKMAN'S COMPENSATION Laws o alifomia." <br /> THE APPLICAW,MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed x TitlLL40T Date <br /> SEE SITE MAP IN UNIT IV WORK PLAN. DATED r V LY G, 19 .9 9 <br /> I <br /> J DEPARTMENT USE ONLY l / <br /> Application Accepted By �{ _ Date Issued 11 1�� _ Area rP <br /> Grout Inspection By Date Final Inspection y Date <br /> Destruction Inspection By Date z I <br /> COMMENTS!CONDITIONS: <br /> [ACCOUNTING ONLY: AID# FAC# <br /> E CODES FEE INFO AMOUNT REMITTED CHEC6X3ASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> Oz 6a— i S! NdL � s E3,L, <br /> UNIT IV- 6/1/99/sign bkpg/MI <br />