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CSN,SIie <br />WELL PERMIT APPLICATION FORM UNIT IV <br />SAN JOAQUIN CWNTY PUBLIC HEALTH SERVICES ORIGINAL <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) I <br />C <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 rw <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED T. <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 coR;pliance with <br />San Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, EnvironmentaLHealth Division. <br />Assesso(a <br />II <br />WELL Location IS -07— N. L Qncn Cross Street 1 rx) ity - C K -i Y�) Zip Parcel# �-O� :r w <br />PROPERTY OwnerTl'ZW HAeL -ZV41 Ll, Address. 1�.�o�`,J ( tU�l(t. �p� �)ZC�_ty qi Zip 9) Phone' <br />C-57 Contractor 6 -- G L� 4-irJCi Address SU ' 0wf- RD Cityt�l 1t.Z7Zip `l5l 7Z Lic#��(d�hJne# 313 -'S <br />Consultant I Sub Contractor j &1eCbeA'i7fh1 Address/ 33 A Ii&a LY - —&ttdAa Phone# 9&-.3500 <br />.5TL at 1 <br />GIS Coordinates: X <br />Y <br />Township Range Section <br />CHECK # REC'D BY <br />WORK TO BE PERFORMED <br />NEW WELL /BORING <br />(CPT, GEOPR_OBE, H_YDROPUNCH HAND -AUGER, OTHER-) 0 DESTRUCTION (choose type below; <br />SOIL BORING # - y �S 14 0 OVER -BORE <br />WELL # <br />0 PRESSURE GROUT <br />'Other:_ _ <br />COMMENTS: <br />TYPE OF WELL <br />INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS <br />�) <br />0 MONITORING <br />0 HOLLOW STEM <br />DIA. OF BOREHOLE MULTIPLE CASINGS? 0 YES 0 NO WELL CASING DIA' <br />\ <br />0 EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />CASING THICKNESS "JIA TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />0 VAPOR <br />0 MUD ROTARY <br />DEPTH OF GROUT SEAL-" SU TREMIE TYPE TO BE USED: 0 AUGERS AHOSE <br />0 AIR SPARGE <br />'PUSH POINT <br />GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />\ <br />� <br />c-' <br />0 SOIL BORING <br />0 HAND AUGER <br />APPROX. BORING DEPTH 5b 1 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />0 OTHER:__0 <br />OTHER <br />CONDUCTOR CASING PROPOSED? / ( if YES, list specifications here) <br />COMMENTS: L r. <br />S'� L�JEOl.Ic�%J <br />�� 7 /47,Jo Z1 Zozm <br />l.. <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 WORKERS' COMPENSATION Laws of California." Contractor's hiring or sub- <br />contracting signature certifies the following:"/ certify that in the performance of the work for which this permit is issued,/ shall employ persons subject to <br />WORKERS' COMPENSATION Laws of California." <br />TH 'AP-. L M�JST BALL 48 WQRKIN,G :HRSaN ADVAi�CE FOR;I4LL REQUIRED INSPECTIONS. <br />Signed x v < "tf zet— Title [�ff j'C�! �fiiii%�/mm,41ate 611710 6 <br />SEE SITE MAP IN UNIT IV WORK PLAN DATED: May t v' �� A^'0 <br />A'c�.v��m <br />DEPARTMENT USE ONLY NO �� <br />Application Accepted By Date Issued �?'�� Area <br />Grout Inspection By Date Final Inspection By Date ll LZ�C <br />Destruction Inspection By Date _ _ ----- <br />COMMENTS I CONDITIONS: <br />//•L 7-00 <br />ACCOUNTING ONLY: AID# <br />PE CODES <br />FEE INFO AMOUNT REMITTED <br />CHECK # REC'D BY <br />DATE PERMIT / SERVICE REQUEST # INVOICE <br />12 -87 <br />-LZ OO 235 <br />C-57 LICENSED CONTRACTOR MUST SIGN.LICENSEWORKER.$''CO ` ION DECLARATION <br />