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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) 468-3450 <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 />t:k M c T E R -y Assessor's <br />WELL Location ii A R D I tV G W r'1 i Cross Street L r\ N E City, 5 G t RT O N Zip ') 52 C I Parcel# <br />5AN TGAG,viN (2C9) <br />PROPERTY Owner CA I IA G t -K C 01 C C E R Y Address V C L; O 3•T City S FG L� TC N Zip 3 5 2G I Phone# 1W 1& 201 <br />tett;-�• Mft11r%N _I )It 553 L50tcf (5zs) <br />C-57 Contractor b 0 t u L 114 G- ,E T E 5 C t N Ir Address 9 5 G Ii GyJ t R C A D City Zip Lic# Phone# 3 t'i 5$ C 0 <br />iltAtdctk0 <br />Consultant / Sub Contractor ISN tvl A lr t 1`l V • Address IAC 13 y ' City My ik 11`- FH Lic# 5 C Phone# <br />GIS Coordinates: <br />.Y <br />Tov:n3hip <br />Range-. _.__ Section <br />WORK TO BE PERFORMED <br />\ <br />1 NEW WELL / BORING (CPT GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER') <br />0 DESTRUCTION (choose type below) <br />® SOIL BORING # <br />G` f - i A ; 'Z� 3, `t ; 5 , (, <br />0 OVER -BORE <br />0 WELL # <br />0 PRESSURE GROUT <br />'Other. <br />j� <br />COMMENTS: <br />�\ <br />TYPE OF WELL CONSTRUCTION TYPE <br />CONSTRUCTION SPECIFICATIONS <br />thy+ <br />0 MONITORING 0 HOLLOW STEM <br />DIA. OF BOREHOLE 2- tN MULTIPLE CASINGS? 0 <br />YES 0 NO WELL CASING DIA: <br />OTHER: ii A <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN <br />CASING THICKNESS tai A TYPE OF CASING: <br />0 STEEL 0 PVC 0 <br />HOSE <br />0 VAPOR <br />0 AIR SPARGE <br />I SOIL BORING <br />0 OTHER <br />COMMENTS <br />0 MUD ROTARY DEPTH OF GROUT SEAL T d `v 16G TREMIE TYPE TO BE USED: p AUGERS 11 <br />PUSH POINTt C i T) GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 HAND AUGER APPROX. BORING DEPTH I (- G 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? N r` ( if YES, list specifications here): W A <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 />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, I shall not employ persons subject to WORKMAN'S 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, I shall employ persons subject to <br />WORKMA S C PENSAI-iOi� Laws ui Califurr;ia.' �7C!`T �^Ic <br />E APPLICANT MUST CAL 48 HRS IN ADVANCE FOR ALL REiliii%Ev rtv.. - <br />7 L� / - k( Date I % L u � _- <br />Signed - Title —T <br />SEE SITE MA IN UNIT IV WORK PLAKI. DATED I zG �c1 <br />DEPARTMENT USE ONLY / Ar DC Z <br />Date Issued N 11 2- Areat <br />Application Accepted By Date <br />Grout Inspection By Date ( 17 Final Inspection By <br />Destruction Inspection By <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: <br />PE CODES FEE INFO <br />AID# <br />AMOUNT REMITTED <br />,74`-v <br />UNIT IV - 6/1/99 /sign bkpg/MI <br />Date <br />CHECK#gCASH I RECEIVED BY I DATE I PERMIT/SERVICE REQUEST NUMBER I INVOICE <br />ysi s- ITK �l/czyoz� 7 S� <br />