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DD WELL PERMIT APPLICATION FORM UNIT IV <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />JAN 3 1 2001 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 Health Services, Environmental Health Division <br />Assessor's <br />WELL Location `//9 zN-4/A/ Si Cross Street City Zip 9S171 Parcel# Z14- 51r Z'5 <br />PROPERTY Owner Sl' 5D7/ &y -,e;' Address 11aco A; ducrZipS' $ Phone-, <br />C-57 Contractor VL %?A.B—A:-X Address /tetra L:LAy Sw1GLeoCity0,4�CCr}„i� Zip�y61z Lic# 1Y,14116 Phone <br />Consultant/ Sub Contractor_ <br />GIS Coordinates: X <br />WORK TO BE PERFORMED <br />dress <br />)'NEW WELL/ BORINGCPT GEOPROBE, HYDROPUNCH <br />0 SOIL BORING # <br />0 WELL # <br />'Other: <br />COMMENTS: <br />TYPE OF WELL <br />INSTALLATION TYPE <br />0 MONITORING <br />0 HOLLOW STEM <br />0 EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />0 VAPOR <br />0 MUD ROTARY <br />0 AIR SPARGE <br />PUSH POINT <br />0 SOIL BORING <br />0 HAND AUGER <br />City Lic#. <br />Phone", <br />Township %L S Range e!f Z4 Section AlAul <br />HAND -AUGER, OTHER-) <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE <br />CASING THICKNESS <br />0 DESTRUCTION (choose type belowi <br />0 OVER -BORE <br />0 PRESSURE GROUT <br />MULTIPLE CASINGS? 0 YES 0 NO <br />R <br />WELL CASING DIA ;_ <br />TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER. ' <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS DHOSE <br />GROUT SEAL PUMPED: 0 Yes D No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') 0A <br />APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />0 OTHER: e,, % 0 OTHER CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <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 Ruies <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 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 />CA THE UNIT IV IN ECR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />Signed x_ - / Title/Company <br />Print Name �D X 1r Date <br />SEE SITE MAP IN UNIT IV WORK PLAN DATED: <br />Application Accepted By <br />` <br />TMENT USE ONLY <br />Date Issued <br />32, <br />20o <br />Area. <br />Grout Inspection By <br />Date anal Inspection By <br />Date <br />Destruction In <br />I CONQITIONS: <br />Date <br />tftt 00 <br />K-FurQ <br />ACCOUNTING ONLY: AID# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # EY <br />DATE <br />PERMIT/ SERVICE REQUEST # INVOICE <br />WM <br />� �SrLGR#---oog��l <br />tftt 00 <br />K-FurQ <br />