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r <br />WELL PERMIT APPLICATION FORM <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 <br />UNIT IV <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 />WELL Location \ y 1` f W. �� 5� S T q Assessor's <br />Cross Street C V% -\s mgr City 1 r�� y Zip 153 b Parcel# -XS 13 • Zoo - p 1 <br />PROPERTY Owner c a. .� G �e \ho Address 1yZ� W • \��~ si City roc Zip rl S 3'1 b Phone# 2- 09 - 3 S -242-1 <br />Po 13 't2-o9oJ <br />C-57 Contractor � VJ �-, VV' ,A Address si- Lko. City i51��� Zip Sb ll Lic# Phone# `l _ -I- -1 -�� 1 0 1 <br />Consultant/ Sub Contractor Z `� vJ�C.re. J Address D-') `�\ t. ,Jn r Lo�- City Yry ka Lic# Phone# Z o Ci -S 92 - b \4 Z <br />GIS Coordinates: X Y , Township i 5 Range S G Section <br />WORK TO BE PERFORMED <br />0 NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) <br />0 SOIL BORING # <br />0 WELL # <br />"Other: <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRt1rTION .RpFripireTInNc <br />DESTRUCTION (choose type below) <br />OVER -BORE 3 rti W <br />I PRESSURE GROUTS %hW <br />N <br />$ MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE MULTIPLE CASINGS? 0 YES 0 NO WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS OHOSE <br />0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: p Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 301) <br />0 SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH <br />0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />0 OTHER: 0 OTHER CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br />COMMENTS: <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 wort: <br />for which this permit is issued, I shall not employ persons subject to WORKERS' COMPENSATION Laws of California." Contractor's hiring or sun - <br />contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, l shall employ persons subject to <br />WORKERS' COMPENSATION Laws of California." <br />Signed <br />SEE SITE MAP IN UNIT IV WORK PLAN DATED: <br />"1 10-,) <br />nl15l00 <br />DEPARTMENT USE ONLY <br />Application Accepted By ✓rn Date Issued I -l-)- 6 d Area ( y <br />Grout Inspection By Date Final Inspection By Date I U J <br />Destruction Inspection By Date <br />COMMENTS/ CONDITIONS: M LA-) I ry\ W I V\ tAJ t7 p r; p e �)U p-- V -e,4 4 u <br />new <br />ACCOUNTING ONLY: AID# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT ! SERVIC EQUEST # INVOICE <br />+�•.y �^'� # y� �r <br />UNIT IV - 6/23/99 /sign bkpg/MI <br />Z 'd WObd Nd90 : 0 666[ -SZ -CI <br />