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WELL PERMIT APPLICATION FORM <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 />UNIT IV <br />SAL <br />dN- <br />4;�Ie"ar <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 <br />r 9-11.15.3 and the Standards of San Joaquin County Public <br />- Health Services, Environmental Health Division. <br />Assesso�r W,, ' S+ll y k -(0-k Zip Pa cel# r'll� <br />WELL Location 7•-f7.bt �5� Mll,,! N Cross D Cit C ,_ J 0 2— <br />PROPERTYOwneY ��F 1 v f Address_City ^ &C � Zipj'�Ihone _.5� j <br />C-57 Contractor i Address�T�1l1Q MGC CityN Zip�lLic#L�16SPhone# Z - U D <br />�+�/' 11 p <br />r. -G. � <br />Consultant /Sub Contractor r Vliil AddressSrOl( (SWt, %o0� (c: (t 1 Y{G�ity�c �Lic#�C Phone#�Q((� Q t-Z!}a <br />GIS Coordinates: X Y Township (V Range Section <br />WORK TO BE PERFORMED <br />*EW WELL / BORING (CP , GEOPROBE, YDROPUNC HAND -AUGER, OTHER") <br />!! &SOIL BORING <br />0 WELL # <br />"Other <br />COMMENTS: <br />TYPE OF WELL <br />0 MONITORING <br />0 EXTRACTION <br />0 VAPOR <br />0 HOLLOW STEM <br />0 AIR HAMMER/DRIVEN <br />0 MUD ROTARY <br />0 AIR SPARGE 0 PUSH POINT <br />'SOIL BORING 0 HAND AUGER <br />'0 OTHER: XOTHER ' n <br />COMMENTS <br />J <br />S <br />S <br />V11, <br />0 DESTRUCTION (choose type below) <br />0 OVER -BORE <br />0 PRESSURE GROUT <br />�• 71) <br />DIA. OF BOREHOLE ^ G- MULTIPLE CASINGS? 0 YES `9�0 WELL CASING DIA:_IdZXt . <br />CASING THICKNESS—V-61'Q- TYPE OF CASING: `HER! <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS _IOSE <br />GROUT SEAL PUMPED: Yes p No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />APPROX. BORING DEPTH 160 " (22D / <br />CONDUCTOR CASING PROPOSED? KV ( 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, 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 />„TATE APPLICANT MUST CALL 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />Signed xy/ �u� �t�—_-�� 1� )(rt4e-f'yIIQGQyt� yI�L17Y((UA41'�itle Ike, Date�L <br />SEE SITE MAP IN UNIT IV WORK PLAN DATED: <br />DEPARTMENT USE ONLY <br />Application Accepted By Date Issued l�' [ r Q Area <br />Grout Inspection By Date Final Inspection By T Date <br />Destruction Inspection By Date ;r Z <br />COMMENTS / CONDITI <br />ACCOUNTING ONLY: AID# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />ERMIT / S T # <br />INVOICE <br />ry <br />p J <br />®0311F <br />C-57 LICENSED CONTRACTOR MUST SIGN LICENSE &WORKERS' -COMPENSATION DECLARATION <br />UNIT IV - 6/23/99 /sign bkpg/MI <br />