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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 /> 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 /> WELLLocation�� pA� t--(oLJ (Sly r-4 Cross Street 1 it4�' City O o/ Zip Parcel# <br /> PROPERTY Owner—) k, Ott - 1 1�'"1-t�4MAgddress �QO N�- SLAW�• City-5 -ic Zip�S Phone# <br /> C-57 ContractorG�"QA9 h- ///r/r4 Address fs/C i�L 4ioj City �(n ip� Lic#_�10 Phone# Z-5 313-Sgoo' <br /> Consultant/Sub Conlraclorigf— MD,-;g �nc.j,,,, ut.�Address P,O,� �( CityS0 ft0 3 Lic#_Phone#�� 53J'W4,C> <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> -- NEW WELL/BORING(CP-T.GEOPROSE,HYDROPUNCH.HAND-AUGER,OTHER') 0 DESTRUCTION(choose type below) <br /> o SOIL BORING# 0 OVER-BORE <br /> WELL# Mw-Z —3 Mw--S p PRESSURE GROUT <br /> 'Other: Q <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 'MONITORING (HOLLOW STEM DIA.OF BOREHOLE IO fr MULTIPLE CASINGS?0 YES XNO WELL CASING DIA' y f <br /> 0 EXTRACTION U AIR HAMMER/DRIVEN CASING THICKNESSS,=L-,410 TYPE OF CASING: 0 STEEL ' PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL So TREMIE TYPE TO BE USED: a AUGERS '91OSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED ) 'Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING p HAND AUGER APPROX.BORING DEPTH --'40 $OLTEO TRAFFIC BOX or Q STOVE PIPE <br /> 0 OTHER OTHER CONDUCTOR CASING PROPOSED? /✓O (if YES,list specifications here): <br /> COMMENTS: t" S <br /> NOTE: OFFS E 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 in the performance of the work for which this permit is issued, 1 shall employ persons subject to <br /> WORKERS'COMPENSATION Laws of California." <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HRS IN ADVANCE FOR ALL /REQUIRED/INSPECTIONS. <br /> Signed x -.�-�s 8'— ,A,� Title/Company—5-44—t-�' <br /> Print Name Grp�J0 /�'/4r-7 /t, Date <br /> l DEPARTMENT USE ONLY <br /> Application Accepted By/'o Dale Issued 9 Area/� U <br /> Grout Inspection By Dale Final Inspection By Dalu 2-, b <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PE # INVOICE <br /> SR# 003( 0311 <br /> 1/18/2000 <br />