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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) 468-3449 <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 />I Assessor's <br />WELL Location 14(t IV. E( DorcLotc Cross Street 44Gt�cc�c, City // 57��7 Zip9S�Z Parcel# <br />PROPERTY Owner GSR Add+drress3GS `I bor-r�.do S%�--City �1Zip`�S2`ZPhone# <br />C-57 Contractor`t- <br />_�c �9S c-� � nS Address q:5c. 47-0,� Rcl City Pkk c>"t� <br />i'-Zipj`f-SS3Lic# ` SSI�S Phone# � C'I <br />Consultant/ Sub ContractoK .� r-Joa 6,�, �,TMa*1Address Z40 aT - City:5011arYINLk Lic# Phone#69'-4 <br />GIS Coordinates: <br />WORK TO BE PERFORMED <br />Townsh <br />0 NEW WELL / BORING (CP.T, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) <br />0 SOIL BORING # <br />0 WELL # <br />'Other <br />CnMMFNTS: <br />Range Section <br />DESTRUCTION (choose type below) <br />,OVER -BORE <br />WRESSURE GROUT <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />>:f,1ONITORING (HOLLOW STEM DIA. OF BOREHOLE MULTIPLE CASINGS? 0 YES 0 NO WELL CASING DIA: <br />- <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: O STEEL O PVC D OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: O AUGERS OHOSE <br />0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />0 OTHER: O 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: "I certify that in the performance of the work <br />for which this permit is issued,/ shall not employ persons subject to WORKERS' COMPENSATION Laws of Califomia." Contractor's hiring or sub- <br />contracting signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, I shall employ persons subject to <br />WORKERS' COMPENSATION Laws of California." <br />CALL THE NI IV I TOR 48 WORKING HRS IN ADVANCE FOR ALL'REQUIRED INSPECTIONS. <br />Signed xA. Title/Company /1IL/�I �■�1 /�'�IA�?�P�'/ <br />DEPARTMENT USE ONLY Application Accepted By (lb'Q h Date Issued /Oc) Area <br />Grout Inspection By Date Final Inspection By (�4 4,jAr"i Date �C- <br />Destruction <br />COMMENTS I CONDITI <br />Date <br />ACCOUNTING ONLY: AID# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />CT <br />REC'D BY <br />DATE PERMIT / SERVICE REQUEST # INVOICE <br />3 5C) <br />6 c) , d <br />�` <br />3 <br />1/1d/CUUU <br />