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.N <br />WELL PERMIT APPLICATION FORM UNIT IV <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) ORIGINAL <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 />� C // __� `,) �] I �f Assessor's <br />WELL Location �C' I ���i) l 1Jt�� / I I1� Cross Street , 1 �'t �1cS City �' � �%t Zip "t Z`"[ Parcel# <br />PROPERTY Owner Wi t S "/� k(� ,L�Address �� % 9���5� City Zip"752 � Pyh�one# ��� lb&C/ <br />C-57 Contractor �51— rW Z rig � Address 3L� 5 f I �rE'�d City je Zip =y&ic4_ 1�hone# 7 <br />%Ik 2s7�5 Z 7y , <br />,b <br />Consultant /Sub Contractormf9Qitl'x_ ��s���ddress"Tc�1SN, lN1 City 7 ? c# Phone# <br />GIS Coordinates: X Y Township Range Section <br />WORK TO BE PERFORMED <br />IEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER') 0 DESTRUCTION (choose type below) (A <br />` 0 SOIL BORING # 0 OVER -BORE d <br />0 WELL # 0 PRESSURE GROUT <br />'Other: ~ <br />COMMENTS: <br />TYPE OF WELL <br />INSTALLATION TYPE <br />MONITORINGFiOLLOW <br />STEM <br />EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />0 VAPOR <br />0 MUD ROTARY <br />FAIR SPARGE <br />0 PUSH POINT <br />0 SOIL BORING <br />0 HAND AUGER <br />0 OTHER:_o <br />OTHER <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE �� k MULTIPLE CASINGS?JJ�YES 0 NO WELL CASING DIA <br />CASING THICKNESS `1 t TYPE OF CASING: 0 STEEL PVC 0 OTHER: <br />DEPTH OF GROUT SEAL /Ii'TREMIE TYPE TO BE USED: GAUGERS $HOSE <br />GROUT SEAL PUMPED: 1j1y,1es p No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />APPROX. BORING DEPTI�O/3i i�f-v T )�_40LTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? /JA ( if YES, list specifications here): <br />COMMENTS: -<c5,,/ L 1-J- jv 1 ;J. <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, l 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_G Title/Company i <br />Print Name WI ��� / / Dated—�1� <br />SEE SITE MAP IN UNIT IV WORK PLAN DATED: <br />DEPARTMENT USE ONLY <br />Application Accepted By Date Issued 67-/7- 00 Area O � <br />Grout Inspection By Date Final Inspection By,,Qate <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# <br />FACA <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PER ST # <br />INVOICE <br />iso <br />MwSR#DZ2. <br />g <br />1/18/2000 <br />