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WELL PERMIT APPLICATION FORM UNIT IV <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) APP 14 2000 <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 jDevelopment Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />aIQj�J `YY� �tiy `-6� 7�� Parcel# is <br />WELL Location //�� 1 Cross//Street City Zip <br />PROPERTY Owner (f es -''jLZte i) Addxdrress 00 �` 6- /� Citys Zip -- <br />r, q mPhone# ,?3- 7" 3 ` <br />C-57 Contractor Vl4YtL'D �i2� ddress `t��� kaQ'( 0,diAc�City�ip is#�o0`�lPhone# ! l// <br />Consultant / Sub Contractor ' L/ VO Address City Lic# Phone# <br />GIS Coordinates: X Y Township Range Section <br />WORK TO BE PERFORMED <br />,R,NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) 0 DESTRUCTION (choose type below) <br />,2-5011- BORING # 0 OVER -BORE <br />0 WELL # 0 PRESSURE GROUT <br />'Other: <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />,nONITORING 0.1`lOLLOW STEM DIA. OF BOREHOLE 2 n 8+1 MULTIPLE CASINGS? 0 YES ,< WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS VIOL TYPE OF CASING: 0 STEEL ,8 -PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS OHOSE <br />0 AIR SPARGE ZPUSH POINT GROUT SEAL PUMPED: 0 Yes ZNo (NOTE: MAXIMUM FREE -FALL DEPTH IS 301) <br />SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH 5 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />0 OTHER:_0 OTHER CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br />COMMENTS: T <br />+Q- e al i <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: 'Y 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 />CALL THE UNIT IV INSPECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />Signed x Title/Company (✓�%[S Z <br />Print Nemo%/ii/% / [ f%J�,r i �� ) //(/ Date 7` / _ �i <br />3EE SITE MAP IN UNIT IV <br />Application Accepted By ✓ <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS / CONDITIONS: 1S 'p,�--/m,4, 4C <br />WORK PLAN DATED: <br />DERAR,TMENT USE ONLY <br />al Inspection By <br />rej <br />0- <br />14 <br />ZV <br />l/ <br />ACCOUNTING ONLY: <br />AID# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PER T # <br />INVOICE <br />s 01 <br />MOO <br />�s9(51 <br />Lt /13/0 d <br />J R CO -o <br />�IrWW -__-_- - - 1/18/2000 <br />