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WELL PERMIT APPLICATION FORM SNI Q! <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 2120l�a( <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 Joaai n (;ounty Develooment Title. Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />v/� Assessor's <br />WELL Location 1-t rVAt. X66 Cross Street N�l ry��ity 51u�ICTfl ,1 'Zip �15� - % Parcel# <br />PROPERTY Owner / ss�� J_ <br />6 . �A L7ro1V Address 2 L.Z� s�-LL:_:�� — — Cit 1 S c. <br />y_ S 1<.0 IG%>r�Zip Phorie# Y(b� cs .� ,} <br />w� �s1 ►-k) z (mi - <br />C -57 Contractor fir , 11. , 5—Address Z3 3 r t } Z C;,N� �2_City C QrO c, Zip 1`51 LLic#SS Y�7o7 Phone# CI <br />Consultant /Sub ContractorAddressy�q S' !U, �. b!".) V City • 57 . i� Lic# (� S., 7 Z 2 Phone# =t� t/�, 7/Q -3 -to <br />/ Ko <br />GIS Coordinates: X , Y , Township / %LI Range 6 F Sectionzt( <br />WORK TO BE PERFORMED ` <br />NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER") 0 DESTRUCTION (choose type below}��' <br />SOIL BORING # <br />0 OVER -BORE <br />'Other. // <br />`\\WELL # /Vj y" 0 PRESSURE GROU d <br />COMMENTS: <br />COMMENTS: <br />k,Urvs I Nuc I IUN SPECIFICATIONS 7 <br />DIA. OF BOREHOLE It MULTIPLE CASINGS ?AYES ONO WELL CASING DIA: Zirlc ) <br />CASING THICKNESSS`)-Mjc C TYPE OF CASING: 0 STEEL KVC 0 OTHER: <br />DEPTH OF GROUT SEAL'—? F�< -}+ TREMIE TYPE TO BE USED: ft1GERS FOSE <br />GROUT SEAL PUMPED:)<Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />APPROX. BORING DEPTH'5S r- i `- 1 �OLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <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 followinc: "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 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 />WORKERS' COMPENSATION Laws of California." <br />jtjg APPLIC NT MUST CALL 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />�C/^ n c <br />Sicned x Tit7 Date r <br />SEE SITE MAP IN UNIT IV WORK PLAN DATED: c� ckMO "t T4 -o <br />DEPARTMENT USE ONLY (� <br />Application Accepted By_:::4 Date Issued _ I�f —(O U Area Q o <br />Grout Inspection By Date Final Inspection By Date <br />Destruction Inspection By Date /1 <br />COMMENTS / CONDITIONS: <br />­ I MLLM 1 1U 1 T rt <br />MONITORING <br />HOLLOW STEM <br />0 EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />0 VAPOR <br />0 MUD ROTARY <br />0 AIR SPARGE <br />0 PUSH POINT <br />0 SOIL BORING <br />0 HAND AUGER <br />0 OTHER:_O <br />OTHER_ <br />COMMENTS: <br />k,Urvs I Nuc I IUN SPECIFICATIONS 7 <br />DIA. OF BOREHOLE It MULTIPLE CASINGS ?AYES ONO WELL CASING DIA: Zirlc ) <br />CASING THICKNESSS`)-Mjc C TYPE OF CASING: 0 STEEL KVC 0 OTHER: <br />DEPTH OF GROUT SEAL'—? F�< -}+ TREMIE TYPE TO BE USED: ft1GERS FOSE <br />GROUT SEAL PUMPED:)<Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />APPROX. BORING DEPTH'5S r- i `- 1 �OLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <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 followinc: "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 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 />WORKERS' COMPENSATION Laws of California." <br />jtjg APPLIC NT MUST CALL 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />�C/^ n c <br />Sicned x Tit7 Date r <br />SEE SITE MAP IN UNIT IV WORK PLAN DATED: c� ckMO "t T4 -o <br />DEPARTMENT USE ONLY (� <br />Application Accepted By_:::4 Date Issued _ I�f —(O U Area Q o <br />Grout Inspection By Date Final Inspection By Date <br />Destruction Inspection By Date /1 <br />COMMENTS / CONDITIONS: <br />WN I RAC OR MUST SIGN LICENSE &WORKERS' ENSAT LARATION <br />UNIT IV - 6/23/99 /sign bkpg/MI <br />ACCOUNTINEONLY: <br />AID# <br />PE CODESAMOUNT <br />REMITTED <br />CHECK # <br />REC'D BY DATE <br />PERMI T INVOICE <br />?9 <br />WN I RAC OR MUST SIGN LICENSE &WORKERS' ENSAT LARATION <br />UNIT IV - 6/23/99 /sign bkpg/MI <br />