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1-28-2003 8: 1SAM FROM P. 3 <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES `Py <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) FILE co <br /> 304 E. Weber, Third Floor, 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 /> Assessor's <br /> WELL Location Cross Street QmL ST City ZipIS316 Parcel-- 13,L'1.y0'b0 <br /> PROPERTY Owner W Address log-4,Q wmL"., My.' City L. A Zip Q2 Phone#3 10 &2? 1 WO <br /> C-57 Contractor lrodAddress �,�4 S� -r CityA CA ZipgJU Li "o Phone# S%b 2to(e 014�p <br /> consultant!Sub Contractor� V, _ NSI Gt Address 31210 yyTT ti Z City t�4L c# Phone#52y <br /> GIS Coordinates:X 'Y Township Rang= Section <br /> WORK TO BE PERFORMED <br /> �td�>AFiafEtt/ ORIN <br /> (CPT.GEOPROBE HPDR (PUNCH.HAND-AUGER,OTHER*) 0 DESTRUCTION(choose type belo)v4 <br /> gL ORING# 0 OVER-BORE <br /> ELL# 0 PRESSURE GROUT <br /> 'Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 20� MULTIPLE CASINGS?0 YES ONO WELL CASING DIA- <br /> - <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTH_R. <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS OHOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes g No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 'SOIL BORING 0 HAND AUGER APPROX.BORING DEPTH M2 t 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER:— OTHER Cs1mT CONDUCTOR CASING PROPOSED? I (if YES.list specifications here): <br /> COMMENTS• knI or tAA nl 2' rJ bcCtntiS Sgtt l <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 Rues <br /> 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 /> for which this permit is Issued,1 shall not employ persons subject to WORKERS'COMPENSATION taws of California." Contractor's hiring or sub- <br /> contracting sionature certifies thef wi g: "1 certifX that in the performance of the work for which this perrnit is Issued.I shell employ persons subject to <br /> WORKERS'COMPENSATION ws Galifomia.' <br /> ALL HE U NSPECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed x Title/Company11't,4419 t/rlcy f.}c'� [ uL' <br /> Print Name Date <br /> SEE SIT(=' P SIN I:1NIT EVz TED <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Issued / O O Areae! <br /> Grout Inspection By T �� Date 1 O O Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID;; EACA , <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK!# RECD BY DATE PERMIT/SERVICE REQUEST# INVOICE <br />