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�'-D <br />WELL PERMIT APPLICATION FORivi UNIT IV <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />QQ JUL304 E' V.,Ver, 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 />1 1 Assessor's <br />WELL Location 355- L 01 el- I�I�f31: R14CC Cross Street �yWrg!v-k V)'. City 0`6%(- L Q <br />Zip 5_ 5)6- Parcel# <br />PROPERTY Owner /kIy- lo " i")."rre" N Address � l X15 CC -� S�16c+ City to I)&Cbl Zip % Phone�i11� U5 1 <br />C-57 Contractor A"/ E- Address '1��fi� ��- ��-�Il�jn'^)�`r' City ii r Zip?i �`Lic# r�'f-�� <br />Consultant / Sub Contractor Address UDS 100` City .S�fi r Lic# 00� 1.0 Phone4,gel o-/Pgg <br />lU� <br />V <br />GIS Coordinates <br />WORK TO BE PERFORMED <br />Township <br />'NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH HAND -AUGER, OTHER-) <br />,,(SOIL BORING # P..I �" y <br />0 WELL # <br />'Other: <br />COMMENTS: <br />TYPE OF WELL <br />0 MONITORING <br />0 EXTRACTION <br />0 VAPOR <br />0 AIR SPARGE <br />SOIL BORING <br />0 OTHER: <br />COMMENTS <br />Range Section <br />0 DESTRUCTION (choose type below) <br />0 OVER -BORE <br />0 PRESSURE GROUT <br />INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 HOLLOW STEM DIA. OF BOREHOLE :�" MULTIPLE CASINGS? 0 YES ,O WELL CASING DIA: At'4 <br />0 AIR HAMMER/DRIVEN CASING THICKNESS �TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS RHOSE <br />_gPUSH POINT GROUT SEAL PUMPED: 0 Yes ['No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 HAND AUGER APPROX. BORING DEPTH PD 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />_0 OTHER 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 following: "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." Contractors hiring or sub- <br />contracting signature certifies the following: "I certify that in the performance of the wort; for which this permit is issued, 1 shall employ persons subject to <br />WORKERS' COMPENSATION Laws of California. " <br />CALL THE UNIT IV INSPECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />Signed x ►) ei/i�, /�ti✓ /�� Title/Company 3' � 6,i,l��!/ i <br />Print Name �'^iab'1 Al I I ����"� Date <br />SEE SITE MAP IN UNIT IV WORK PLAN DATED: <br />DEPARTMENT USE ONLY <br />Application Accepted By 6t- Date Issued %— yf Area <br />Grout Inspection By Date Final Inspection By Date <br />Destruction Inspection By "�C- jt. Date '?1/341-) ��s ��� �c _, _ _ to / — q, 0"-" <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PERMI INVOICE <br />�- _ 8/2000 <br />