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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) 468-3450 <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 />WELL Location 3 9 Z M r F F A T b 4 V D. Cross Street C H E R M A K AVCity MA N T C C A Zip 9 5 3 3 E Parcel# Z211 -03 -CV <br />SAN;fC/>,GvttJ CCt;t�TY <br />PROPERTY OwnerFACit-1TES MC -MT. DErl, Address I}22 F• b[CTT) AV; - City STG(KTCN Zip9520� Phone#Z04-q{b --335-{ <br />C-57Contractor V,1 W t7f1ILL1N(;•, (NL.. Address e C, 30x '}IL City E5L(--FVN Zip)yE i Lic#J1Q90'.Phone# lkt— T}} 41CC <br />vZ/tNCttC R.G. <br />Consultant/ Sub Contractor RIa 11 A 1r E ENV • Address (� C � C' % e C'> _City MV, I C TA Lic# 5 Phone# `> IE 3-5 ZS C' <br />GIS Coordinates. X , Y- , Township Range Section <br />WORK TO BE PERFORMED <br />NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER`) 0 DESTRUCTION (choose type below) <br />0 SOIL BORING # p OVER -BORE <br />1 WELL # M W'- I i"1 W? �M VV 3 0 PRESSURE GROUT <br />`Other: <br />COMMENTS: <br />TYPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br />I MONITORING I HOLLOW STEM DIA. OF BOREHOLE V- tN MULTIPLE CASINGS? 0 YES S NO WELL CASING DIA <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS SLN 4(; TYPE OF CASING: 0 STEEL I PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 13 - F r TREMIE TYPE TO BE USED: J AUGERS OHOSE <br />0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes I No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING O HAND AUGER APPROX. BORING DEPTH 3 C F r I BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />0 OTHER: CONDUCTOR CASING PROPOSED? 110 ( 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 certify that in the performance of the work <br />for which this permit is issued, I shall not employ persons subject to WORKMAN'S 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 />WORKMAN'S COMPENSATION Law of California. " <br />THE PLI NT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INS NS. <br />�`����' <br />Title -per°�y Date <br />Signed <br />SEE SITE MAP IN UNIT IV WORK PLAN. DATED IC It11 )9 jMAP ATTR Cifq) <br />DEPARTMENT USE ONLY <br />/r Date Issued Z oD Area <br />Application Accepted By <br />Grout Inspection By <br />ate 12,1 I Qo Final inspection By I /�� c r Date <br />Destruction Inspection By Dale <br />COMMENTS I CONDITIONS: <br />.il <br />�..1 <br />UNIT IV - 6/1/99 /sign bkpg/MI <br />