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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 R t It I W 5 R C (Z G� Cross Street �o0l s �Ivl City F-ye� cG C `t'M h Zip Parcel# <br />PROPERTY Owner S`�'� JC4 . Ott u�1121 <br />1 2c ?) <br />`� h hf� Address 1}21l:SccIEvz. City SCOGKCG�t ZipijZCjPhone# t�Q L)Cl <br />C-57Contractor Address 399 1'tts Pl4cr Cityd �ly�, i 145 Zip95LSLLic#a 33 Phone# I 1VV,,,��� <br />prl 1�40'013G/l e69I�(s LsIL) <br />Consultant / Sub Contractor li4 -14 t7 --w rLki M01 I Address Rkhc h G P1 kh I rTQ City `I 5 G > Lic# y , Phone# -354 -5Z S AQ <br />GiS Coordinates: X <br />r <br />Township Range Section <br />WORK TO BE PERFORMED <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK#/CASH <br />RECEIVED BY <br />DATE T NUMBER <br />INVOICE <br />1 NEW WELL / BORING <br />( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) 0 DESTRUCTION (choose type below) <br />J SOIL BORING # <br />0 OVER -BORE <br />0 WELL # <br />0 PRESSURE GROUT <br />P <br />`Other: <br />COMMENTS: <br />TYPE OF WELL <br />CONSTRUCTION TYPE <br />CONSTRUCTION SPECIFICATIONS <br />0 MONITORING <br />0 HOLLOW STEM <br />DIA. OF BOREHOLE 2-W MULTIPLE CASINGS? 0 YES f NO WELL CASING DIA: NA <br />�^ <br />0 EXTRACTION <br />0 AIR HAMMERJDRIVEN <br />CASING THICKNESS N A TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: N A <br />0 VAPOR <br />0 MUD ROTARY <br />DEPTH OF GROUT SEAL T O = 2C � T TREMIE TYPE TO BE USED: 0 AUGERS (HOSE <br />0 AIR SPARGE <br />I PUSH POINT <br />GROUT SEAL PUMPED: 0 Yes I No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />1 SOIL BORING <br />0 HAND AUGER <br />APPROX. BORING DEPTH 'LC - FT. 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />0 OTHER: <br />CONDUCTOR CASING PROPOSED?. N ( 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 Laws of California." <br />THE APPLICANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />Signed x - �L Title 122 LX-64 Date ryi ��7 —dIr <br />SEE SITE MAP IN UNIT IV WORKPLAN. DATED Rm5`tst I�, z 0 c I <br />DEPARTMENT USE ONLY <br />�- t( i, ( <br />Application Accepted By "--Ti A �w Date Issued { T Area <br />�j <br />Grout Inspection By �� � _s i -d. Date l�/i �c' Final Inspection By /V1 ,c?� Date j5 ,/% <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />FAC# <br />ACCOUNTING ONLY: AID# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK#/CASH <br />RECEIVED BY <br />DATE T NUMBER <br />INVOICE <br />r1D 0 <br />UNIT IV - 6/1/99 /sign bkpg/MI `� <br />