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2-10-2000 11:24AM FROM P-1 <br />�6UNITWELL PERMIT APPLICATION FORM IV <br />A 9 <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICESTI <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 Q <br />(209) 468-3449 <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 r <br />San Joaquin County Development Title. Chapter S-1115.3 and the Standards of San Joaquin County Public Health Services. Environmental Health Division. ' <br />Assessor's <br />c."J j` C� •\ (7- r Z i Cit I✓c+� Zip Parcel# n) <br />WELL Location �% i t%�t� i Z, i Cross Street Y <br />6•J �lai��^'� <br />PROPERTY Owner . �� �r Address ^M iZ� City. �ZiP Phone# <br />C-57 Contractor (ham ddress ZZ�r l �cvlLd tz✓ , A/f. City P1, i?icl~ wG> p`l �l 6 Lic# ue' Phone# ' <br />A-V C -vLr wvic . <br />Consultant/ Sub Contractor2l�,; - Address <br />GIS Coordinates: X Y Township Range Section <br />�l <br />WORK TO BE PERFORMED JJ <br />0 NEW WELL / BORING ( CPT, GEO PROBE, HYDROPUNCH, HAND -AUGER, OTHER") DESTRUCTION (choose type below) <br />U SOIL BORING # U OVER -BORE <br />0 WELL # Z (c ( j =� PRESSURE GR UT <br />"Other: <br />COMMENTS: 6i �W,& Gu� C ( vii ✓ w L'C+ C- C c�'I�Cv� J . �J <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />p MONITORING 0 HOLLOW STEM DIA, OF BOREHOLE MULTIPLE CASINGS? 0 YES U NO WELL CASING DIA <br />U EXTRACTION U AIR HAMMER/DRiVEN CASING THICKNESS TYPE OF CASING: U STEEL U PVC 0 OTHER: Pv <br />O VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS QHOSE V <br />U AiR SPARGE (] PUSH POINT GROUT SEAL PUMPED: 0 Yes U No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />O SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH U BOLTED TRAFFIC BOX or U STOVE PiPE <br />6 <br />OTHER:_0 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 Cerdfy that in the performance of the work <br />for which this permit is issued, I shall not employ persons subject to WORKERS' COMPENSATION Caws 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 p9rtnit is issued, l shall employ persons subject to <br />WORKERS' COMPENSATION Laws of California. " <br />CALL•THE'UNIT IV IN48 WORKING HRS IN ADVANCE. .FOR ALL REQUIRED INSPECTIONS. <br />Signed / � TitlelCompany L1.�iZ 6,et)(LL's r i-1 �«✓wct er ��"l% <br />-1 <br />y ; i h �L .ik ate <br />Print 1 _ - --- _ - <br />Name D <br />,..,....... ......._.....--.-•,..,,..w... .....,- .. !•� <br />SEE....StfE- <br />DEPARTMENT USE ONLY <br />Application Accepted By ' v ^ c'• <br />Date Issued L I Area <br />r d. Date `( Final Inspection By Date O <br />Grout Inspection By <br />— <br />Destruction inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: I AID# <br />PE CODES I FEE INFO i AMOUNT REMITTED l CHECK # <br />3 -, z- 1 1 6C � 00 I C, fi r-- 1 2) <br />REC'D BY DATE PFRQUEST # INVOICE <br />