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WELL PERMIT APPLICATION FI...M 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 />ment Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environ <br />e mental Health Division <br />San Joaquin County Develop <br />etf /"T Mri43'Cit ti?d�Z—&!:+4 Zip Parcel# 219 <br />WELL Location �3� /�+��� �-+���� Cross Street ( Y <br />PROPERTY Owner r�1Q6 /.As��?�-Address ,�ZiP <br />Y hone, <br />C-57 Contractor 5fir« •NjAddress 953.5 W p,M f 13taL i Q City!STVC e�rhf Zipys Lic#6 jojPhone# <br />Consultant / Sub Contractor <br />GIS Coordinates: X <br />WORK TO BE PERFORMED <br />>ZNEW WELL / BORING ( CPT <br />'Other: <br />COMMENTS: <br />TYPE_ OF WELL <br />,N10NITORING <br />0 EXTRACTION <br />0 VAPOR <br />0 AIR SPARGE <br />0 SOIL BORING <br />Address City Lic# Phone", <br />Y , Townships 5 Range Sectional <br />bele: 'r <br />GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER') 0 DESTRUCTION (choose type <br />OVER-BORE <br />0 SOIL BORING # 0 PRESSURE GROUT -,,!Z% <br />0 WELL # z <br />INSTALLATION TYPE <br />HOLLOW STEM <br />0 AIR HAMMER/DRIVEN <br />0 MUD ROTARY <br />0 PUSH POINT <br />0 HAND AUGER <br />0 OTHER: -0 OTHER <br />c\. <br />UCTION SPECIFICATIONS <br />CONSTR <br />DIA. OF BOREHOLE -8 ��£� MULTIPLE CASINGS? 0 YES )00 WELL CASING DIA: Z.C' VA <br />CASING THICKNESS 5e4/ 'fo TYPE OF CASING: 0 STEEL 9FVC 0 OTHER: <br />DEPTH OF GROUT SEAL S'•c� "jar;�C•TREMIE TYPE TO BE USED: 0 AUGERS `,NOSE <br />GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />APPROX. BORING DEPTH 7-5-:0 + 9DOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( 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 La,,vs, and Rules <br />t's signature certifies the following: "I certify <br />e work <br />and hick this <br />of the s San Joaquin <br />shall not employ persons subject ton WORKERS COMPENSATION Laws o California." Contrat in the ctor's hire of g or sub - <br />for which th p P p y Psubject <br />contracting signature certifies the fallowing: "1 certify that in the performance of the work for which this permit is issued, Ishall em �o persons o <br />WORKERS' COMPENSATION Laws of California. •' <br />C LL THE U)T,IV 48 WORKING HRS IN7ADNCE FOR ALL REQUI ED INSPECTIONS. <br />Title/Company <br />Signed x <br />Date <br />Print Name _ r~/, <br />SEE SITE MAP IN UNIT tv WORK PLAN DATED:: <br />-DEPARTMENT USE ONLY / <br />Application Accepted By <br />Grout Inspection By_ <br />Destruction Inspection E <br />COMMENTS / CONDITI <br />e Issued // / Areas <br />al Inspection By Date <br />ACCOUNTING ONLY: AID# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE P <br />T # INVOICE <br />�� ins�z000 <br />