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f <br />WELL PERMIT APPLICATION FORM UNIT IV <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SER44;­ 0 E V IE 4 <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) F, <br />304 E. Weber, Third Floor, Stockton, CA., 95202 JAN 0 6 2000 <br />(209r 468-3449 <br />E=NVi'RUNNIEN IAL HEALTH <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED`RVI(-t S <br />P E.R'Vl i T S <br />Application is hereby made to San Joaquin County for a permit to construct and/qr 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 />7 � ^ L�L`""t l( 'f'� Assessor's <br />WELL Location DU r`7e � Ler vt-e- Cross Street A V _ City I rA W Zip —j(• Parcel# 2% -30o -412 <br />PROPERTY Owner �r• .'c�,N i f� 11e( Address <br />2r3;'—'dl�,C� '��.yi City_ TZ1Cu -Zip CC,-4,Phone# Zr'rell3,- <br />es( - <br />C -57 Contractor t 1v 1(I Address_ ����; yu c' Roo A. CitYLEIFEgWl Zip 6A Lic# C•`7Phone# <br />Consultant /Sub Contractor_ iPGVYI { ��y 1,Ki( rAof s "Z/Oi 6�1'VJh t.cy �t eC�-) _ <br />-7 C �T Address 12th f- ir.�r City n � , 0 Lic# � — Phone# `SIL w(v3-ZJl�t� <br />GIS Coordinates: X6 f 74 SL Y=LL.4(or'4 -.Township <br />WORK TO BE PERFORMED <br />Range <br />Section <br />0 NEW WELL / BORING ( CPT, GEOPROBE, HYOROPUNCH. HAND -AUGER, OTHER-)(( ` �DESTRUCTI <br />0 SOIL BORING # O (choose type below) <br />0 WELL VER -BORE <br />'Other: <br />*,,PRESSURE GROUT <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE MULTIPLE CASINGS? 0 YES 0 NO WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMI <br />0 AIR SPARGE 0 PUSH POINT <br />E TYPE TO BE USED: 0 AUGERS OHOSE <br />GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30'1 <br />0 SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH <br />0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />0 OTHER:_G OTHER CONDUCTOR CASING PROPOSED? (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 WORKERS' COMPENSATION Laws of California." Contractor's hiring or sub- <br />contracting signature certifies the following: '/certify that in the performance of the work for which this permit is issued,/ shall employ persons subject to <br />WORKERS' COMPENSATION Laws of California." <br />THE APPLICANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />Si-ned x Iwo i' le <br />02"M T <br />SEE SITE MAP IN UNIT IV WORK PLAN DATED <br />DEPARTMENT USE ONLY / 6,6 �� <br />Application Accepted By Date Issued ` ^!� Area <br />Grout Inspection By Date Final Inspection By Date <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: C�I/iCL(/(//(. / it TL!/•L" <br />ACCOUNTING ONLY: AID# <br />FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED CH/EhC/K#/CASH <br />RECEIVED BY <br />DATE PERMIT/SERVICEREQ/U�%E_ST NUMBER <br />INVOICE <br />�2 <br />,/ <br />... <br />�w� O6){ / 60 S ice' <br />Q(Ir1, A6i! <br />„'�' ��tia�1�,�r ���.,�s.,�r�,�s����+tl,.�� �'�E,�`f•.�. �l,C�;l;•;[�f':TC�i�I��;��C��'`r���?'� ��`� ��� hh�� <br />UNIT IV - 6/23/99 /sign bkpg/MI ' <br />7 • J <br />