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WELL PERMIT APPLICATION FORM UNIT IV <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES o <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) APR Q 7 2000 <br />APR 12 2000 304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 ENVIRONMENTAL HEALTH <br />PERMIT/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 <br />San Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />_966t) <br />�� �� �; %/^ < t7.Yl `) Assessor's <br />WELL Location l41, 4� Cross Street / C, City J � Zip Parcel# <br />PROPERTY Owner ti quu aA -Address,-7J32- GZ�4���f/1/lli� TCityS�� Zip lh<d Phone# 47� " '7 <br />C-57 Contractorf dul`y7Le �7> Address 401)!1 zyGL' /t/i Isili City S p Lic# 4�1"GZ%Phone# 7j <br />Co nsu t / Sub Contractor r 1 �•- Address City h Lic# Phone# h <br />GIS Coordinates: X , Y <br />WORK TO BE PERFORMED <br />Township <br />JEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) <br />0 SOIL BORING # <br />0 WELL # <br />'Other._ <br />COMMENTS <br />Range Section <br />0 DESTRUCTION (choose type below) <br />0 OVER -BORE <br />0 PRESSURE GROUT <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE 2JI MULTIPLE CASINGS? 0 YES _ -tlO 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 'TfJ7?3-L- TREMIE TYPE TO BE USED: 0 AUGERS $HOSE <br />0 AIR SPARGE VUSH POINT GROUT SEAL PUMPED: 0 Yes qg No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />OIL BORING 0 HAND AUGER APPROX. BORING DEPTH Sr=E'­r 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />0 OTHER:_0 OTHER , ,CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br />COMMENTS: tvi <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: "1 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 Caiifornia.' Contractor s hiring or sub- <br />contracting signature certifies the following: "1 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 Title/Company �C �. �►' l <br />Print Name A// t��� L Date q9 A& <br />SEE SITE MAP IN UNIT IV WORK PLAN DATED: Z2 Anf- % <br />DEPARTMENT USE ONLY <br />Application Accepted By UJ OIF, L20MDate Issued <br />Grout Inspection By cc,K ate "_/Z D Final Inspection B , <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# <br />PEttCC�ODES <br />FEE INFO <br />AMOO�UNT REMITTED <br />CHECK # REC'D BY <br />DATE <br />P T # <br />INVOICE <br />/PT __ 1/1/2000 <br />I <br />