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22-1999 9 : 26At l FROt t P. 2 <br />WELL PERMIT APPLICATION FORM UNIT IV <br />SAN jOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL_ HEALTH DIVISION ("PHS-EHD") <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3450 <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 desen'bed- This application is made in compliance with <br />San Joaquin County DevAlooment ritle. Ch 9-1? 15.3 and the Standards of San Joaquin County Public Health Services. Environmental Health Division.. <br />LV S r Assessor`s <br />WELL Location - Cross Street ff—o-lt City STTock-lzN Zip Parcel# I � - tit -, <br />PROPERTY Owner UA-LEtS1 &xvt I/" Address Lwl N \Q' ­ ,+ City 1,70cK%V Zip iS&L Phone# <br />Sl. <br />., tc+ y <br />� <br />r`.57 CantraC,ort ksO�' tnlJhlt NmENi-Ac Address,jl t_ S ell S _City SP�� --Zip LiC#L� (a Pnoneic <br />Consultant I Sub Contractor- Address City LiC# Phone#. <br />GIS Coordinates: X Y, Township Range Sectlon <br />WORK TO BE PERFORMED <br />(j''NEW WELL I BORING CPT, G &ROB ,\ HYOROPUNCH, HAND -AUGER OTHER`) Q DESTRUCTION (choose type below) <br />OIL BORING # a OVER -BORE <br />aLL # 0 PRESSURE GROUT <br />WE <br />-Other: <br />C :.'LAMENTS: <br />3 EXTRACTION a AIR HAMMER/ORIVEN <br />Q VAPOR a MUD ROTARY <br />� AIR SPARGE QOUSH POINT <br />j] SOIL BORING a HAND AUGER <br />DL-, OF BOREHOLE 01L" MULTIPLE CASINGS? a YES a NO WELL CASING DIA: <br />CASING THICKNESS TYPO OF CASING: 13 STEEL 0 PVC a OTHER: <br />DEPTH OF GROUT SEAL T \�i TREMIE TYPE TO BE USED: a AUGERS 0HOSE <br />GROUT SEAL PUMPE=D: Q Yes g o(NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />APPROX. BORING OEPTH = `' jb,.J Q BOLTED TRAFFIC BOX or a STOVE PIPE <br />CONDUCTOR CASING PROPOSED? 1,116 i if YES, fist specifications here): <br />COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS! <br />nereby 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 ceniries 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 WORKMAN'S COMPENSATION taws of California." Contractors hiring or sub- <br />rontracbng signature certifies the following: -1 Certify that in the performence of the work for which this pamrit is issued, 1 shall employ persons Subject to <br />vVORKMAN'S COAfPENSA77ON Laws of COOOMIa•' <br />THE APPLICANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />Signed x kg� &� 'R�'- <br />-actk, rVVItLVTE(t4Title 'A r -'r ENG11Nt '� Oate �'Z3I`i 7 <br />�I <br />C� <br />SEE SITE MAP 1 UNIT IV WORK PLAN DATED <br />(/—6EPAR ENT USE ONLY q <br />Date Issued <br />Area <br />Application Accepted BytltOaeFinal Inspection By <br />Gout Inspection S <br />jQ <br />ate <br />flestructivn Inspection By <br />COMMENTS I CONDITIONS: <br />FACiA <br />ACCOUNTING ONLY: AID# <br />PE CODES FEE INFO AAAOUNT REMITTED CHECK#ICASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE <br />G�mss, I dA� - <br />