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WELL PERMIT APPLICATION FORivI UNIT IV <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) r� <br />'X47E. Weber, Third Floor, Stockton, CA., 95202 R <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 />fi I Assessor's <br />WELL Location f Il}t.! ri'54 P!40 - Cross StreetrDmihe/'0,i4 tbl'- City I r��c Zip /Parcel# <br />–r .�)(ller' } Y�LfL p r: r�Phone# ��r�r9� ¢��� ' X7/6 <br />PROPERTY Owner /-/Tt`�1 l Ir �•"I Address i)`i_i� 6�s�(_� Cit a Zi <br />C-57 Contractor Abr \ Address `-fi)Q� �/ crt�ye%'? tic ity . hxklrr) Zip r 1 -OJ Lic# ))) Phone#,)i�` -% <br />Consultant / Sub Contractor A6Address cW57 ",q City c c "-+n Lic#�,' 0,22 Phone4_,�)9 f PVL'? <br />GIS Coordinates: X , Y <br />WORK TO BE PERFORMED <br />Townshi <br />,t(NEW WELL /BORING ( CPT, GEOPROBE, HYDROP�UNCH, ND -AUGER, OTHER') <br />.SOIL BORING # <br />0 WELL # <br />'Other: <br />COMMENTS <br />Range <br />Section <br />0 DESTRUCTION (choose type below) <br />0 OVER -BORE <br />0 PRESSURE GROUT <br />TYPE OF WELL <br />INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS <br />PE CODES <br />0 MONITORING <br />0 HOLLOW STEM <br />DIA. OF BOREHOLE d MULTIPLE CASINGS? 0 YES 100 WELL CASING DIA <br />REC'D BY <br />0 EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />0 VAPOR <br />0 MUD ROTARY <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS NHOSE <br />0 AIR SPARGE <br />:PUSH POINT <br />GROUT SEAL PUMPED: 0 Yes .$'No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />_SOIL BORING <br />0 HAND AUGER <br />APPROX. BORING DEPTH Q 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />�v <br />0 OTHER:_0 <br />OTHER <br />CONDUCTOR CASING PROPOSED? . if YES, list specifications here). <br />COMMENTS: <br />NOTE: <br />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." Contractors 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 />CALL THE UNIT IV INS ECTOR 48 WORKING HRS IN ADVANCE FOR ALL <br />/REQUIRED INSPECTIONS. <br />Signed x �" Avg '�J Title/Company �T�+ {�� ! �-i <br />I•_ <br />Print Name (iCcr' I ' �f✓liA✓I Date <br />SEE SITE MAP IN UNIT IV WORK PLAN DAT / <br />DEPARTMENT USE ONLY / <br />Application Accepted By "wue <br />z"rte C�" Date Issd 7 — i c Area e' f <br />Grout Inspection By Date a�Final Inspection By Date <br />Destruction Inspection By d�� r�-1 �- -� –�'u 1 Qat x.j c,.f�-+•'r <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: <br />AID# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PERMIT / SERVICE R­5Q1JEc4T # <br />INVOICE <br />q 33i? <br />1/18/2000 <br />