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WELL PERMIT APPLICATION FORM 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 San <br />Joaquin Development Title, Chapter 9-1115.3 and the Standards of San Jo um County rubuc Health Services, Environmental realm urvision. <br />-rib <br />Assessor's <br />WELL LocatioMJ� Cross Street- i t y 5 2a-9JE4LZip_Parcel# <br />PROPERTY Owner - - Addrress �nCity �J D� KID�t ?Zipj%S�Phone# <br />C-57 Contractor s PFr f Qom' ' Address a Do2S r ' `fit P City j ! Zip Lic# Phone# <br />y- -r 0 <br />Consultant / Sub Contractor /-,j,n t Int, LL. 1%� Address 1271.5 rA/JU,.i C('-- City �Z Lic# 7S22hone# <br />GIS Coordinates: X , Y , Township Range Section <br />WORK TO BE PERFORMED: <br />UAtvy WELL / BORING ( CPT, GEOPROBE, HYDROPrCH�I�AND-AUGER, OTHER-) <br />aSOIL BORING # Ill <br />[]WELL# k- RI <br />'Other: <br />COMMENTS: <br />TYPE OF WELL <br />INSTALLATION TYPE <br />g -MONITORING <br />0.1-iOLLOW STEM <br />[] EXTRACTION <br />[] AIR HAMMER/DRIVEN <br />[] VAPOR <br />[] MUD ROTARY <br />0 AIR SPARGE <br />[] PUSH POINT <br />[] SOIL BORING <br />[] HAND AUGER <br />0 OTHER:_0 <br />OTHER <br />COMME <br />0 DESTRUCTION (choose type below) <br />0 OVER -BORE <br />0 PRESSURE GROUT <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE MULTIPLE CASINGS? 0 YES 0 NO WELL CASING DIA: <br />CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS QHOSE <br />GROUT SEAL PUMPED: [] Yes p No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />APPROX. BORING DEPTH (., i o BOLTED TRAFFIC BOX or [] STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( 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, 1 shall employ persons subject to <br />WORKERS' COMPENSATION Laws of California." <br />Signed x <br />Print Name <br />*,GALL/TH-E UNIT IV INSPECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS <br />Title/Company <br />SITE FILE ADDRESSfWORK PLAN DATE: <br />Application Accepted By <br />Grout Inspection By_ <br />Destruction Inspection B <br />to / / /7/c' C> <br />LY ll <br />Date Issued I ] V <br />Date Final Inspection By <br />Date <br />L <br />1 - <br />ACCOUNTING ONLY: AID# FACIt <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />IT / INVOICE <br />R Ro� a <br />C-57 exp._ WC/waiver C-57 Letter of Authorization to sign permit ----E-ncroachment doc(s). -----"7/00 <br />