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WELL PERMIT APPLICATION FORM UNIT IV <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />`L SIENVIRONMENTAL HEALTH DIVISION (PHS-EHD) - <br />o} 304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 ORIGINAL <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 <br />,Title, <br />,Chapter 9.1115.3 and the Standards of San Joaquin County Public Health Services, Environ <br />esstal'S Health Division <br />WELL Location 2-1�"✓"' /'""' Glu b > yd Cross Street �� Avg City S LI` 10►, Zip�b20 Farce 1# <br />I21 -21 -06 <br />PROPERTY Owner -I" I'e �� In C. Address 1022D OR <br />S V 4 E3r!Crt�rq CityF9r4l, -��I _ZiP!17'� Phone, S o3 91-7. 114-$ <br />�7, u <br />C-57 Contractor 9.C;Ei ✓1�u-=^th Address ISD HDwE AyE City A1�►+EZ Zip�`� Lic#48616� Phone# 9 313 5$00 <br />Consultant/ Sub Contractor TT cOxp•' Address 400q Fh¢TGH1tAW "City .dt-6nD Lic#194 Phone # • 7-3`10 <br />GIS Coordinates: <br />Y <br />Towns <br />WORK TO BE PERFORMED <br />NEW WELL! BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) <br />0 SOIL BORING # <br />Q�NELL # MW' <br />'Other: <br />COMMENTS <br />Range Section <br />0 DESTRUCTION (choose type below! <br />0 OVER -BORE <br />0 PRESSURE GROUT <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS u <br />(MONITORING HOLLOW STEM DIA. OF BOREHOLE S " MULTIPLE CASINGS? 0 YES JNO WELL CASING DIA: Z- <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CA GH *0 TYPE OF CASING: 0 STEEL ePVC 0 OTHER: <br />0 VAPOR O MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS OHOSE <br />O AIR SPARGE p PUSH POINT Yes �No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH . .'BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />OTHER SING PROPOSED? ( if YES, list specifications here): <br />0 OTHER:_O A f <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 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 />CALL THE UNIT IV INSPECTOR 48 WORKING HRS IN ADVANCE __FOR ALL REQUIRED INSPECTIONS. <br />Signed x <br />Title/Company IT' 60 r;L_p 7t2A7 I Or`I <br />Print Name <br />I ►Vl -P, Date <br />SEESIT AP. IN UNIT IV WORK PLAN,. DATED: " <br />DEPARTMENT USE ONLY �j <br />Application Accepted B Date Issued /O Zi �U Area �v — <br />p Y TZID <br />..QQ� <br />Grout Inspection By Date Final Inspection By COM Date <br />Destruction Inspection By A Date <br />ACCOUNTING ONLY: Al D# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DAT P T # INVOICE <br />o 2- 8" <br />1/18/2000 <br />