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WELL PERMIT APPLICATION FORM UNIT IV <br />SAID} JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION ("PHS-EHD") <br />304 E. Weber, Third Floor, Stockton, CA., 95202 ORIGINAL <br />(209) 468-3450 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />Arioxation 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 />L✓ / Assessor's <br />'HELL Location <br />//S 5� �C : �� �T . Cross Street tv1'e, XCity r( Zip � Z.-3 Parcel# <br />. } L <br />PROPERTY Owner 71 — e S I �s �- Address City Zip Phone# <br />57 Contractor L <br />L'ddress �� c' City Jr- Jr /71�( Zip 7L`f Lic# ' Phone# `i/4 " 7 <br />U , Srt�L fzk _'t J� 1�,�, -77Z 3,(Z <br />Consultant / Sub Contractor L�C,FaLjb e 4,4 <br />Address U ti O;ty Lim Phone# <br />GIS Coordinates: X <br />Y <br />Township Range Section <br />'NORK TO BE PERFORMED <br />NEW WELL/ BORING ( CPT, GEOPROBE, HYDROPUNCH, <br />HAND -AUGER, OTHER') 0 DESTRUCTION (choose type below] <br />OVER -BORE <br />SOIL BORING #— <br />PRESSURE GROUT <br />- <br />ELL # <br />Fit <br />0 <br />Other: <br />CCMMENTS: <br />I <br />-YPE OF WELL <br />CONSTRUCTION TYPE <br />CONSTRUCTION SPECIFICATIONS <br />j MONITORING] <br />HCL -IOW STEM <br />DIA. OF BOREHOLE `r MULTIPLE CASINGS? 0 YES 0 NO WELL CASING DIA: <br />=XTRACTION <br />0 AIR HAMMER/DRIVEN <br />CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />VAPOR <br />0 MUD ROTARY <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0HCSE <br />AIR. SPARGE <br />0 PUSH POINT <br />GROUT SEAL PUMPED: 0 Yes p No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />;zSCIL BORING <br />0 HAND AUGER <br />APPROX. BORING DE. TH BOLTED TRAFFIC BOX or 0 STOVE PIPs <br />0 OTHER: <br />CONDUCTOR CASING PROPOSED ( if YES, list specufications here): <br />COMMENT <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 Ruies <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 WORKMAN'S COMPENSATION Laws of California." Contractor's hiring or sub- <br />=ontracting signature certifies the following: 'I certify that in the performance of the work for which this permit is issued. I snail employ persons subject to <br />WORKMAN'S COMPENSATION Laws of California.' <br />THE APPLICANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />Signed x�' ��+t�L Title <br />SEE SITE MAP I NIT IV WORK PLAN. DATED Z)z�h� <br />DEPARTMENT USE ONLY <br />Application Accepted By Date Issued Area <br />Grout Inspection By Date Final Inspection By Date <br />Destruction Inspection By Date =- <br />"OMMENTS / CONDITIONS: <br />FAC# <br />ACCOUNTING ONLY: AID# i <br />PE CODES FEE INFO I AMOUNT REMITTED CHECK#ICASH RECEIVED BY DATE P UEST NUMBER INVOICE <br />M( 3 <br />UNIT IV - 5/99 /MI <br />