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WELL PERMIT APPLICATION FORM 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 R I G I N A L <br /> /SID/5 �''` <br /> I. NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> %pplication 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 CountyyDevelopment Title,Chapter 9-1115.3 and the Standards.of San Joaquin County Public Health Servpices, EnvironmentalAssessor, <br /> Health_, _ -5 I <br /> NELL Location /57-fol--6.n� c` r- ' - .%rocs Street L city L R.0 Zip /S33n ParceWt7-(a0 1 I„ <br /> ?ROPERTY Ownei fi O -' Address-AP 7��City L —Zip 95330 Phone# �B-��j 329 <br /> (q Ib) <br /> 536© S.V4frLf ny6, cit S Zip Li z&1 Phone# <br /> -57 ContractorMDe fAJJrJ+eJJ Drl I. ddress y c#67 7 zov) ! <br /> ADV'rt ' L t -I , <br /> 3 7onsultant/Sub Contractor 6eD CNV►t'CrJm&,IH Address 'IOOS-/��Wt��'N W�r City 7DG�mA: Lic# Phone# 4rv1—lUU Co <br /> 1 <br /> 31S Coordinates:X ,y.,Township Range Section <br /> NORK TO BE PERFORMED <br /> pffW WELL I BORING(CPT,GEOPROBE,HYDROPUNCH, HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> +. D SOIL BORINGS 0 OVER-BORE <br /> Q"WELL# �1 A«— I E� ./ii if s �7 0 PRESSURE GROUT <br /> -Other: <br /> COMMENTS: i'.. <br /> I' <br /> i TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS / <br /> ONITORING OLLOW STEM DIA.OF BOREHOLE 8" MULTIPLE CASINGS?0 YES (0'NO WELL CASING DIA:7, <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS S - 40 TYPE OF CASING: 0 STEEL (,&4�< 0 OTHER: <br /> O VAPOR D MUD ROTARY DEPTH OF GROUT SEAL JO G r TREMIE TYPE TO BE USED: R,<GGERS DHOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes �ylo'(NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING - D HAND AUGER APPROX. BORING DEPTH2S� OLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER:_9 OTHER CONDUCTOR CASING PROPOSED? A10 (if YES, list specifications here): <br /> j 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 San Joaquin County Ordinances,State Laws,and Rules <br /> j 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 /> I 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, /shall employ persons subject to <br /> If WORKERS'COMPENSATION Laws of California." <br /> CALL THE VNIT IV INSPECTOR 48 WORKING HRS IN ADVANCE FOR ALL REE(7]UIRED INSPECTIONS. <br /> S/ \ / ,y/ADY C�0 <br /> I Signed x / �Il 1 - Title/Company S F�7CpC�IS'/�+pnF.�✓t Pl�tht�C fif+t 11144= <br /> Print Name /ons P'�1KRGlc�f Dale e7/z. /a�`�M v`� -t tsfn�IR'f7Cn.7 Iti2,P,r' <br /> i S E SITE MAP_r IN UNIT IV WORK PLAN DA ED <br /> DEPARTMENT USE ONLY <br /> Application Accepted By �' '� �� Date Issued T- <br /> Grout Inspection By Date_ - Final Inspection By <br /> Destruction Inspection By p Date WOO/ <br /> I� COMMENTS I CONDITIONS: <br /> 1 <br /> I <br /> ACCOUNTING ONLY: AID# ' PAra <br /> 1 PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 350 t MVJ � 140 3 = 3t) 0023989 <br /> 1/18/2000 <br />