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WELL PERMIT APPLICATION FORM UNIT IV <br />1 D <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERA/ 1= ll " Lid <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) ; _ - X005 <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 +��/�nU�1'1`;r;,i; HEALM <br />�-TRflMT/SERVICES <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 San <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />1�Assessor's <br />WELL Location 7%`' y rvct-c-1,, Cross Street t- Ilrw v✓u ty Zip 1jZ1 ZParcel# i 3 0u3c, IQ <br />PROPERTY Owner l� 1 t Address 3i-�Vc S <br />z,,..,LnCity —re TZip 1�153(Phone# <br />C-57 Con tractor Address 7773 W L., City c, Zip 3 `! uc 1G_ Phone# 623 .-96 (4 - I'S <br />5 Pj `� � .�ic <br /># ) <br />Consultant/ Sub Contractor �w.(� r,'� Address ',D `7C -3 I'{� I (�-� City E r^' Lic# -� Phone# <br />GIS Coordinates: X , Y <br />K TO BE PERFORMED <br />Township <br />'VNEW WELL / BORING ( CPT, GEOPROSE, HYDROPUNCH, HAND -AUGER, OTHER") <br />SOIL BORING # <br />WELL # I co <br />`Other: <br />Range Section <br />0 DESTRUCTION (choose type below) <br />0 OVER -BORE <br />0 PRESSURE GROUT <br />COMMENTS: r`�' 1=� 5 e--) h-,-t4� 4- Pr � y_­c- �,�L_ -t- -, 1-,-3 C- 14 j 6 2_ Z <br />TYPE OF WELL <br />l�"MON�NG <br />0 EXTRACTION <br />0 VAPOR <br />0 AIR SPARGE <br />0 SOIL BORING <br />INSTALLATION TYPE <br />0 HOLLOW STEM <br />0 AIR HAMMER/DRIVEN <br />0 MUD ROTARY <br />0 PUSH POINT <br />0 HAND AUGER <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE MULTIPLE CASINGS? 0 YES 0 NO WELL CASING DIA: <br />CASING THICKNESS TYPE OF CASING: O STEEL 0 PVC 0 OTHER: <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: O AUGERS OHOSE <br />GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />APPROX. BORING DE <br />O OTHER: 0 OTHER CONDUCTOR CASING PROPOSED? <br />0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />( if YES, list specifications here): <br />COMMENTS: -rx IIi;✓:�4" yy�11y-c� <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, 1 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, I shall employ persons subject to <br />WORKERS' COMPENSATION Laws of California." <br />CALL THE UNIT IV INSPECTOR 48 WORKI,G.HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />Signed x- Title/CompanyG7c�.. <br />Print Name <br />Date /o <br />DEPARTMENT USE ONLY <br />Application Accepted B 141tpq Date Issued <br />Grout Inspection By � (_ L� f .� Date 0 mon Final Inspection By <br />Destruction <br />COMMENTS / CON <br />Date <br />Z /U� Area ? 72 <br />Date <br />ACCOUNTING ONLY: AID# <br />PE CODES <br />FEE INFO AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PER T # <br />INVOICE <br />//V/01 <br />o vv,(, <br />�-- ; iii 9/2CCC <br />