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WELL PERMIT APPLICATION FuRM UNIT IV <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ��' 7 l. -Ai- HAL iH <br />ENVIRONMENTAL HEALTH DIVISION ("PHS- &D;;29 <br />rpvmf304 E. Weber, Third Floor, Stockton, CA., 95 > Ppb 4: 05 <br />(209) 468-3450 <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 />� /�� Assessor's <br />WELL Location ,�j�Q S�—SCc.(o i�`� Cross Street City Zip 32) Parcel# <br />PROPERTY Owner/4-1 T?rrlr((-1 �12U� , Address ZIA>4 �v. J,x Ci Zip Phone# <br />C-57 Contra <br />Consultant/ Sub Contractor ALN . K f7 <br />GIS Coordinates: X Y Township <br />WORK TO BE PERFORMED <br />. .NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) <br />9=SOIL BORING # <br />Q WELL # <br />'Other: <br />COMMENTS <br />hone# - <br />ity& Lic# Phone#:22K`5724f/KL <br />Range Section <br />Q DESTRUCTION (choose type below) <br />Q OVER -BORE <br />Q PRESSURE GROUT <br />TYPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br />Q MONITORING Q HOLLOW STEM DIA. OF BOREHOLE MULTIPLE CASINGS? Q YES Q NO WELL CASING DIA: <br />Q EXTRACTION Q AIR HAMMERJORIVEN CASING THICKNESS TYPE OF CASING: Q STEEL Q PVC Q OTHER: <br />Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL,TREMIE TYPE TO BE USED: Q AUGERS QHOSE <br />Q AIR SPARGE —4 PUSH POINT GROUT SEAL PUMPED: ,.Yes Q No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />i SOIL BORING Q HAND AUGER APPROX. BORING DEPTH 2C-, - 4;7 Q BOLTED TRAFFIC BOX or Q STOVE PIPE <br />Q OTHER: CONDUCTOR CASING PROPOSED? m ,s ( 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 work <br />for which this permit is issued,/ shall not employ persons subject to WORKMAN'S 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, f shall employ persons subject to <br />WORKMAN'S COMPENSATION Laws of California." <br />HE APPLICANT MUST CALL 40^ HRS 1N ADVANCE FOR ALL REGAUIRED INSPECTIONS. <br />Signed x Title ( � Lt 5 - 4 ti ,,— Date / �og�w V J <br />SEE SITE MAP IN UNIT IV WORK PLAN. DATED <br />DEPARTMENT USE ONLY <br />Application Accepted By Date Issued>3 Area <br />Grout Inspection By Date 6 03 Final Inspection By (J, Ae--I,ti Date <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: <br />AID# <br />FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CyHECK#/CASH RECEIVED BY <br />DATE PERMITlS T NUMBER <br />INVOICE <br />S' p <br />� coal C) C, <br />f''�--Z-14� <br />g /S R# C0 <br />C -5T LICENSED CONTRACTOR; MUST_ SIGN LICENSE & WORKE S°�C DECLARATION <br />UNIT IV - 6/18/99 /sign bkpg/MI <br />w <br />0 <br />