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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 />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />UNIT IV <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 />Assessor's <br />WELL Location �n:e� sego., I) C -e t�v t Cross Street ` � Ceram( City Tmcy Zip 95376 Parcel# C o� Tr..c <br />PROPERTY Owner C` n Address 3219 C . iO4. 5�,ee.4- City -Tmc. Zip 45376 Phone# 20 g -83 i -w t Zo <br />C-57Contractor CAScode Unl�`r9 Address 3632 D►Mcc C%,r`C1e City (_,40 V_, Zip 9S 1q2 Lic#717510 Phone#916-633- 1165 <br />Da��d �Ne�zo 1 2o,„�ko <br />Consultant/ Sub Contractor 6a+}ter-�7aa51r�t Address 3106old Ca..,p Dry 170 City Cordova Lic# 7 2 11 Phone#916-63 1 - 1300 <br />GIS Coordinates <br />WORK TO BE PERFORMED <br />Township <br />0 NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER`) <br />0 SOIL BORING # t,WELL # I I -k <br />14 <br />'Other: <br />COMMENTS <br />TYPE OF WELL <br />INSTALLATION TYPE <br />0 MONITORING <br />0 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 />CONSTRUCTION SPECIFICATIONS <br />Rang <br />Section <br />DESTRUCTION (choose type bel <br />DOVER -BORE <br />0 PRESSURE GRC <br />DIA. OF BOREHOLE 11 MULTIPLE CASINGS? 0 YES ONO WELL CASING DIA: <br />CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS HOS <br />GROUT SEAL PUMPED ,�YesoNOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />APPROX. BORING DEPT 2."�u.� t p BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />0 OTHER:—O OTHER CONDUCTOR CASING PROPOSED? <br />( if YES, list specifications here): <br />NOTE: OFFSITE BORI GS 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: 'I certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to <br />WORKERS' COMPENSATION Laws of California." <br />TH£-APPMANT MUST CALL 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />Signed x <br />SEE SITE MAP I <br />Application Accepted By_ <br />Grout Inspection By <br />Title SEN\Or 2C`IM 15� Date 8 2 �' <br />NIT IV WORK PLAN DATED. g`Z�l0 <br />DEPARTMENT USE ONLY /Ip / �, / * <br />Date Issued 1G,L Areae <br />to Final Inspection By Date? • O Z <br />Destruction Inspection By V Date <br />COMMENTS / CONDITIONS: 04 Of` <br />—0 1L 101 <br />ACCOUNTING ONLY: AID# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DAT <br />PERMIT-/ UEST # <br />INVOICE <br />3sc�2 <br />�A� <br />3$g <br />lSIRZ-� <br />I <br />C-57 LICENSED CONTRACTOR MUST SIGN LICENSE &WORKERS' C;UMYEl-sl I IUJN LLl,LA1CA l lviv <br />UNIT IV - 6/23/99 /sign bkpg/MI <br />