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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 Coun��ty��yyDevelopment Title,Chapter 9-_11115.3 and the Standards of San Joaquin County Public Health Services,Environmental a Health Division <br /> WELL Location;(' AttL(q�01 �� r' Cross Street rl_�-4�+L^C'ity o/ o Zip Parcel# Q�� -�17D ' 0'9 <br /> PROPERTY Ownerl—, <br /> G�.-119%J,,.,Addne s 400 N. SI�gW FA. City-:5 a 4c Zip s Phone# <br /> /� Address ISC 1tQGyt �o�A� City t- ip� Lic# �Phone# Z.5 313-S oo <br /> C-57 ContractorC��^�__ rte— ct} <br /> // f Address P O $ q City1 0�o^'R Lic# i7 _ <br /> Phone#�� <br /> Consultant I Sub Contracto'-"4 �i4 tas�- ,,,. � <br /> GIS Coordinates:X <br /> Y Township Range Section <br /> WORK TO BE PERFORMED <br /> NEW WELL/BORING(CRT, GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) Q DESTRUCTION(choose type below) <br /> # 0 OVER-BORE <br /> SOIL BORING <br /> WELL# MtU-� PRESSURE GROUT <br /> 'Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS !� / <br /> MONITORING HOLLOW STEM DIA OF BOREHOLE Io t r MULTIPLE CASINGS?0 YES XNO WELL CASING DIA I I <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESSSr—I-. O TYPE OF CASING: 0 STEEL 'KPVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL_SO TREMIE TYPE TO BE USED: 0 AUGERS �I IOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: ` `fes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER APPROX.BORING DEPTH O <br /> OLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER:_G OTHER CONDUCTOR CASING PROPOSED? /✓O (if YES,list specifications here): <br /> COMMENTS: �/ t <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: 'Y certify that in the performance of the work <br /> for which this permit is issued,t shall not emp/oypersons 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, I shall employ persons subject to <br /> WORKERS'COMPENSATION Laws of California." <br /> RS IN ADVANCE FOR /REQ/UIRED/INSPECTIONS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING H <br /> Signed x -�-.-� <br /> ��� Title/Companys7cc"TT Gd0Lo4'3t/ C�QMpr'iG <br /> Date Zy oz <br /> Print Name <br /> DEPARTMENT USE ONLY <br /> Date Issued � Area <br /> Application Accepted By <br /> 9 <br /> at Is <br /> Grout Inspection L1y I n-k�� Dale D Z-- Final Inspection Dy Dett� <br /> Destruction Inspection By Dale <br /> COMMENTS/CONDITIONS: <br /> EMPECODESLFEE <br /> # _ <br /> OUNT REMITTED CHECK# REC'D BYDATE PERM[ REQ # INVOI <br /> ------- - 1/18/2000 <br />