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f <br />WELL PERMIT APPLICATION FvRM UNIT IV <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD)r - <br />304 E. Weber, Third Floor, Stockton, CA., 95202 A10: �5 <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 Assessor's <br />Health Division <br />-lad-n-4Sa0� <br />WELL Location ►ua E 11�►cd..�.t .}+may SS Cross Street V vt'a- SI, City SiQ..�.l•Y, -Zip. Parcel# <br />.' Imo. i•Add ess 1'•0 "AJL 5 �0 CityMdg.�s.NQA,YrS�ip 4L Phone L� it;.4-1 ST <br />PROPERTY Ownersy rno^n lad -n— dd.� 4S-1- <br />y �W Or�ll�:.� I»t, Addressloa S+~ s4rcA+ City Isle�er. ZipySV`II Lic#'72-59° Phone# I 777-4100 <br />C-57 Contractor <br />I t? <br />Consultant / Sub Contractor %Irk- Qss�••I �S kms- • Address %IQ ►.nine palm 4Zy City lrlod,a&` o Lic# Phone# 574' Z�1 <br />GIS Coordinates <br />WORK TO BE PERFORMED <br />)4NEW WELL <!Eq CPT <br />'Other: <br />COMMENTS: <br />Y <br />Townsh <br />,GEOPROBE,YDROPUNC AND GER, OTHER-) <br />0 SOIL BORING # 58 <br />0 WELL # <br />Range Section <br />0 DESTRUCTION (choose type below) <br />0 OVER -BORE <br />0 PRESSURE GROUT <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS - r- [) 9 A N WELLCASINGDIA: <br />0 MONITORING ;'HOLLOW STEM DIA. OF BOREHOLE MULTIPLE CAST ffVVOO W <br />0 EX (RACTiON 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE O¢F C4�;�Ni����Q �!T;��L"'1E�r`rc• �� OTHER <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL -jyr� T{ E~_ 0 AUGERS OHOSE <br />0 AIR SPARGE D PUSH POINT <br />GROUT SEAL PUMPED: Yes 011- (N)M)A �IMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH SS 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />0 OTHER:__0 OTHER CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br />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 />and Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: "1 certify that in the performance of the work <br />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, 1 shall employ persons subject to <br />WORKERS' COMPENSATION Laws of California." <br />CALL THE UNIT IV INSPECTOR 48 WORKING HRS IN ADVANCE IFOR ALL REQUIRED INSPECTIONS. <br />Q Title/Company9, Q •-` GaQ 1= T %� T�• �SSdt �o: e s vtiC - <br />Signed x e`^ i <br />Print Name �c �^ �- �t o'^ Datey Z-- Z - 2.da� <br />SEE SITE 'MAP IN UNIT IV WORK PLAN DATED: <br />DEPARTMENT USE ONLY <br />Date Issued <br />Application Accepted By Date <br />Date Final Inspection By <br />Grout Inspection By <br />nestruction Inspection By Date <br />COMMENTS I <br />ACCOUNTING ONLY: <br />PE CODES FEE INFO <br />AID# <br />AMOUNT REMITTED <br />8-`l <br />CHECK # I REC'D BY I DATE <br />313 1 e0 1,4)a,�1 <br />INVOICE <br />1/18/2000 <br />