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Allio "A4 <br />WELL PERMIT APPLICATION FURM UNIT IV <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION ("PHS-EHD") o <br />304 E. Weber, Third Floor, Stockton, CA., 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 ca 11*011 <br />San Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental 0" h. <br />.?.Z3 LjGglc.'M� s. - Cross Street City Zip Assessors <br />. ' Parcel# <br />WELL Location <br />PROPERTY Owner �c�i/r.e✓: Address ` City i Zip31tLPhone# <br />C-57 Contractor V* Lc.% �� Address 6A 6�Mg ! - _ -c ip Uc# d hone#9V6-i9ZiffN <br />Consultant I Sub Contractor <br />31S Coordinates. <br />WORK TO BE PERFORMED <br />Y , Township -_-_• Range Section <br />INEW WELL 1 BORING (CPT. GEOPROSE, HYDROPUNCH, HAND -AUGER, OTHER") _ a DESTRUCTION (choose type below) <br />0 SOIL BORING # Q OVER -BORE <br />,WNELL >t 3 G PRESSURE GROUT <br />'Other: <br />COMMENTS. <br />TYPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br />IfMCNITOR!NG OHOLLOW STEM *DW OF BOREHOLE MULTIPLE CASINGS? DYES ONO WELL CASING DIA: <br />a EXTRACTION a AIR HAMMERIORIVEN CASING THICKNESS TYPE OF CASING: a STEEL Q PVC Q OTHER: <br />Q VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL - TREMIE TYPE TO BE USED: GAUGERS QHOSE <br />o AIR SPARGE a PUSH POINT GROUT SEAL PUMPED: 0 Yes Q No (NOTE: MAXIMUM FREE -FALL DEPTH IS 301) <br />Q SOIL BORING 13 HAND AUGER APPROX. BORING DEPTH Q BOLTED TRAFFIC BOX or Q STOVE PIPE <br />p OTHER: CONDUCTOR CASING PROPOSED? (if YES. list specifications gere): <br />COMMENTS; t r <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS! re'" <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, a <br />and Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: "I certify that kr the performance of the wo <br />for which this permit is Issued, l shall not employ parsons subject to WORKNAWS COMPENSATION laws of California." Contractor'shiring <br />contracting signature certifies the folloanng: 'I Certify that in the performance of Ute work for wtrrch this permit is issued. I shall employ persons sutupct <br />WORKMAN'S COMPEVSA TION Laws of Cakfto ia. " <br />E PPLICANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />Signed x Titlegw4m , � Dale <br />SEE S1 (E MAP IN IT IV WORK PLAN. DATED 4f-z4o-aa _ <br />DEPARTMENT USE ONLY <br />Application Accepted By Date Issued c a Area <br />Grout Inspection By A�.Ib . bA Date 00 Final Inspection By Date.. <br />Destruction Inspection By Date <br />COMMENTS I CONDITIONS: <br />ACCOUNTING ONLY: <br />AID# <br />FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK$JCASH <br />RECEIV D BY <br />DATE <br />PERMITISERVICE REQUEST NUMBER INVOICE <br />440"00 <br />JR# <br />057 UCE qSM CONTRACTOR MUST SIGN' UCENSE &- W0RKEFSh.00I%F bATiVN L)EUEAKA ILUM <br />UNIT:V - 5/18/99 /sign bkpg/MI <br />