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2-10-2000 1 1 : 24AM FROM <br />-n. <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) 468-3449 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />P_ 1 <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 Locationross Street (44." City Zip �� �' Parcel# <br />PROPERTY Owner Address City Zip Phone# <br />C-57Contractor l r Address—h <br />�,V, <-X z7-1) City� rL�Zp `J 7y�Lic#61 (7 Phone#_%IG <br />Con IusTtant/Sub Contractor( lic rw �%f kti Address 3� �5, ("City c �'1 Lic# Phone# �1�C' <br />GIS Coordinates; X <br />WORK TO BE PERFORMED <br />xNEW WELL! BORING ( CPT <br />"Other: <br />COMMENTS <br />Y <br />Township <br />, GEOPROBE. HYDROPUNCH, HAND -AUGER, OTHER*) <br />0 SOIL BORING # <br />0 WELL # 2 <br />Range Section <br />0 DESTRUCTION (choose type below) <br />Q OVER -BORE <br />0 PRESSURE GROUT <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS, <br />MONITORING HOLLOW 5TEM DIA, OF BOREHOLE `� , MULTIPLE CASINGS? 0 YES U NO WELL CASING DIA: Z <br />0 EXTRACTION jj AIR HAMMERIDRIVEN CASING THICKNESS SL `jc TYPE OF CASING: 0 STEEL )iPVC 0 OTHER: <br />Q VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL Y' 'u� TREMIE TYPE TO BE USED Q AUGERS [►HOST <br />0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: (I Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />Q SOIL BORING Q HAND AUGER APPROX. BORING DEPTH 2-5, X'SOLTED TRAFFIC BOX or 0 STOVE PIPE <br />Q <br />OTHER:_0 OTHER CONDUCTOR CASING PROPOSED? ) : (if YES, fist specifications here): <br />COMMENTS <br />i <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, 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 ;n the performance of the work for which this permit is issued, I shall employ persons Subject to <br />WORKERS' COMPENSATION Laws of Cafifomia. " <br />CALL THEUNIT'I IN 48 WORKING HRS IN AD�V�ANCE.FOR-ALL REQUIRED INSPECTIONS. <br />Signed x_ ' ✓ Title/Company d V4- CA- <br />Print <br />ASCccFins �w'c�,v�c r�, <br />r'.lMc Dat <br />Print Name e <br />DEPARTMENT USE ONLY <br />?/ Area <br />Application Accepted By Date Issued <br />Grout Inspection By 1A- Mn C o'i-- __Date 1 106 Final inspection By Date <br />Destruction inspection By Date <br />COMMENTS I CONDITIONS: <br />ACCOUNTING ONLY: I AID# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # REC'D BY <br />DATE <br />PERMIT I SERVICE REQUEST # <br />INVOICE <br />3�d� <br />'Sq. (20 <br />51'- Ak <br />2-SEW0oa <br />L02, <br />