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f <br /> ' L <br /> WELL PERMIT APPLICATION FORM <br /> UNIT 1V <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 458-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES t YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin ounty for a porm4 to construct anc!fq install the work described- This application is made in compliance with <br /> C <br /> San Joaquin County Deveiapmen[Tittr".Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services.Envit�mritat ealth'Division. <br /> sebWeS <br /> WELL Location 10 w <br /> jt/ CrossStreei City /-O D l Zip L�f D Parcels <br /> t3 `v . <br /> PROPERTY Owner `33�G O f elty Llw—v ILl:C Zip��Phonez 4lb T83'Z Lb <br /> - ViV,.LIL.Y 1�4 rTt- 71 <br /> G F VrltlMAV ddr®ss S DJ Citlr, �—LP S hon <br /> C-57 Ccnuactor L' �CP // <br /> Consultant IS Contractor S /ItC. Addrtess - <br /> GIS Coordinates:X - - <br /> Y Township .3� Range Section <br /> WORK TO BE_PERFORMED <br /> YuEw E5i'RUCTiON(choose type below? <br /> r <br /> M WELL!E30R1NG(CPT,9E PROBE.HYDFtOPUNCI- AUGER.,HAN0.AUGER, OTHER-) Q OvER-BORE <br /> . SOIL BORING s '�( )^?RESSURE GROUT <br /> WELL <br />� •atr�r. <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFIGATIONS <br /> MONITORING Q HOLLOW STEM DIA,OF BOR6hiOLE.M MULTIPLE CASINGS?[j YES "�NO WELL CASING Dla; <br /> p E)CTF[ACTION Q AIR HAMMER/DRIVEN CASING THICKNESS_-- - TYPE:OF CASING: []STEEL I]PVC" Q OTHER:TRENtIE TYPE TO BE USED: p aUG6R5;.' pi-�IOSE <br /> VAPOR p MUD ROTARY DEPTH OF GROUT SEAL_ <br /> q]AIR SPARGE %PUSH POINT GROUT SEAL PUMPED: Q Yens XNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING a NANO AUGER APPROX.BORING DEPTH r I�8OLTED TRAFFIC SOX or STOVE PIPE <br /> a OTHER: OTHER CONDUCTOR CASING PROPOSED? (.ifYES.list specific'etions hare): <br /> COMMENTS. <br /> r NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby cer[ify that I have pr+spared tuts application and that the work will be done in accordance with San Joaquin County Ordinance-4s,State Laws,and Rules <br /> and Regulations of the San Joaquin County. Hameowner or licensed agent's Signature certifies the following: "1 certify that in the pe rforrreaneri of the work <br /> 1Sor which this permit is issued,!shall rto[employ persons subject to WORJGERS-COs1PENSATION Laws of Califbmia" Contractor's hiring or sutr <br /> contracting signature certifies the following: 7 certify that in the performance of rhe work for which IhiS permit is issued.1 shall ernpfuy pdrsor►S subject to <br /> WORKERS'COMPENSATION Laws of Catilomia.' <br /> THEAPPU ANT MUST CALL 413 HRS IN ADVANCE FOR ALL REQUIRED'INSPECTIONS- <br /> Tide R�scr .G �o�rir opt.. <br /> 5gned,c <br /> i SEE SITE MAP IN UNIT IV WORKPLAN DATED <br /> DEPARTMENT:USE ONLY <br /> 1. Application Accepted By Date issued Area /40 <br /> Grout Inspection By <br /> Date Final Inspection Sy Date-�— <br /> Deszrunon Inspection By Date <br /> COMMENTSlCONDITIONS- O QCA= G.w' <br />'l FACIE <br /> ACCOUNTING ONLY; A1D# <br /> PE CODES FEE INFO AMOUNT REMITTED CHEC6CASH RECEIVED SY DATE pERtNITlSERVIGE REQUEST NUMBk'R lNYOIC$ <br /> C-57 LICENSED CONTRACTOR MUST SIGN LICENSE 8C"W'ORKERS' COMPENSATION DECLkR4TION <br /> UNIT IV-6/23/99 /sign bkpg/MT <br /> 1` <br />