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MEN <br />ORIGINAL <br />WELL PERMIT APPLICATION FORM UNIT IV <br />SAN JO:AQUIN 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 _oaquin County for a permit to construct and/or install the work described. This application Is made rn compliance with <br />San Joaquin County 'Development Title Ch ter 9-1 115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division <br />� T� t� qr � 7/ Assessur'��� • � %t% -Q� <br />WELL Location Al 7 �� Cross Street G�57; city! ��-/�G��t Zip / f3X Parcel# _. T_ <br />PROPERTY Owner -A dC PAS -IL Address 176 //'- Sr City /�1 Zlo `J37�hcne#V,%-,J0On <br />C-57Contractor -50 <br />Consultant; Sub Contracta.! L'- ...✓ :�-Adc'rsss0(0� / ry C!ts_r 'C� L`c# Phone <br />GIS Coord.nates: X_ (f �_, Y Township___ Range Section <br />WORK TO BE PERFORMED - <br />lillfrNEVV WELL; ©ORING ( CPT, GEC?RCBE HYDROPUN , H N -AUG R. f <br />,SOIL BORING # I, mI <br />L WELL d_ <br />COMMENTS. ' <br />TYPE OF WELL <br />INSTALLATION TYPE <br />] MONITORING <br />O HOLLOW STEM <br />Q EXTRACTION <br />AIR HAMMER/DRIVEN <br />O VAPOR <br />O "BAUD ROTARY <br />O AIR SPARGE <br />X USH POINT <br />.TOIL BORING <br />O HAND AUGER <br />O DTHER:____ <br />O OTHER <br />COIYMENTS:__�� <br />ST _TIO ose tye be <br />plow) <br />' OVER- <br />SSURE.GROUT I <br />DI.A. 01' BOREHOLE MULTIPLE CASINGS? OYES ONO `hE;_L CASING DIA'__._ <br />CASINGTHICKNESS &/ __TYPE OF CASING: O STEEL n PVC O OTHER: <br />DEPTH OF GROUT SEAL -7 REMIE TYPE TO BE USED: GAUGERS OHOSE <br />GROUT SEAL PUh1PED: O Yes ON <br />NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />APPROX, BORING DEPTp BOLTED TRAFFIC BOX or O STOVE PIPE <br />CONDUCTOR CASING PROPOSED? t�V ( If YES. I st specifications <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- Homeowrer or licensed agent's signature certifies the following '7 certify that in the performance of the work <br />for which this permit is issued, ! shall not ampioy persons subject to WORKERS' COMPENSAT10N Laws of Callfornia." Contracto's hiring or sub- <br />contracting signature --ertifies the following: "I certify that In the performance of the work for which This permit is Issued. i shall employ persoms Subject to <br />WORKERS' COMPE.N&ATJON Laws of California." <br />/Signpd <br />THE APPLI ANT MUST CALL 48,WORKING. NRS IN ADVANCE FOAR_ AAL REQUIRED INSSPPECTIGNS. <br />x_ �' Title T�`� D'ate �1- f <br />d� SEE SITE MAP I UNIT IV WORK PLAN DATED: <br />DEPARTMENT USE ONLY <br />Applicator Accepteo By__. __ Date Issued <br />0!,out Inspection By Date_ Final Inspection By <br />Destruction Inspection by <br />COMMENTS f CONDITIONS: <br />1 flrn�, wT!r.:�: nn!! v I anti <br />Date <br />°E CODES FEE INFO j AMOUNT REMITTED <br />_-�50 <br />CHECK # <br />530 <br />REC'D BY <br />DATE PERI4il T; SERVICE T it INVOICE <br />Z�Z� sR# 00.22096 <br />C-57 LICENSED CONTRACTOR MUST SIGN LICENSE WWOKER rt``' Com► fl�-t�titi urs ��1►►�.' <br />UNIT TV - 6/23'/`40 /s!cn bkpg/AOI <br />E .d I^10aA NV9S'6 6661-EZ-ZL <br />E <br />