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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 Qv% ZipcJSHealth Services, Environmental Assessor's <br />Health Division <br />WELL Location �Z1431F Mac aos a Cross Street a City , �o 4tLo Parcel# <br />(}scvwc..n� `,Nt, Address 2431 E �c`(�� (U City ti r Zip 2Z0 6 Phone #?tTj 9+41 2.576 <br />PROPERTY Owner � 37� <br />e,� �r1a Address ZdZ'i Low e�r WSY City o vLZiPy � Lic# Phone#�• 46 Z'76�i 6 <br />C-57 Contractor L�c+•c• k. W : , <br />Consultant ub Contractor a'C� �c-�e-� <br />\oL Address%1%-1 [Gv c lez"6 City Lic#-U . Phone#7139-574'2u1 <br />t k^I <br />GIS Coordinates: <br />WORK TO BE PERFORMED <br />0 NEW WELL / BORING (CPT. GEOPROBE, HYDROPUNCH <br />0 SOIL BORING # <br />0 WELL # <br />Township_ 1t4 Range 1 I=. Sec ion <br />HAND -AUGER, OTHER-) <br />DESTRUCTION (choose type below <br />0 OVER -BORE <br />`!PRESSURE GROUT <br />'Other: <br />COMMENTS: <br />Q�(Lea��•t',v. v.��`1S (Y�,W � �vKi lN��l Z <br />TYPE <br />INSTALLATION TYPE <br />0 MONITORING <br />0 HOLLOW STEM <br />0 EXTRACTION <br />0 AiR HAMMER)DRIVEN <br />0 VAPOR 0 MUD ROTARY <br />0 AIR SPARGE 0 PUSH POINT <br />0 SOIL BORING 0 HAND AUGER <br />0 OTHER:—O OTHER <br />COMMENTS: <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE MULTIPLE CASINGS? 0 YES ONO WELL CASING DIA: <br />TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />CASING THICKNESS \\ <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: O AUGERS OHOSE^ l <br />GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 3� <br />APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or O STOVE PIPE n� <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <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, 1 shall employ persons subject to <br />WORKERS' COMPENSATION Laws of California." <br />C L T IT V INSPECTOR 48 WORKING HRS IN AD/V/A CE FOR ALL REQUIRED/INSPECTIONS. <br />Title/Company v � <br />Signed x <br />Date <br />Print Name <br />ATED <br />SEE SITE ..MAP IN. UNIT IV WORK ,PLAN. D <br />DEPARTMENT USE ONLY ,,/I / <br />Date Issued n�� Area--� <br />Application Accepte*B�� �'/ /DateGrout Inspection By- FinalInspectionB narP <br />