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WELL PERMIT APPLICATION FORM UNIT IV <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) Aij-08 <br />304 E. Weber, Third Floor, Stockton, CA., 95202 ORIGINAL <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 />/ nn t` AftKlyn hv� _ Assessor's <br />WELL Location I�j p : 1 f v L5 Gki)Cross StreetC,,,. Qv City 5 rcyC K! : n Zip 952, , Parcel# <br />n(� <br />VIVO <br />PROPERTY Owner-_jyQ, PtV to SLayi<2 Address -ZISI (t4 t." r_I OVA fiIjOCity_S f oc Ki -:'� Zipc Zv 7Phone# Z2 v1oE 2715 <br />c a „� �ti— RAN��I. <br />C-57Contractor WEST 0 A2,ff-k.4- Address31-33 5J(;?,,}City Zip957YJ-Lic#S phone# S87 71 <br />PPpp Dr i II.. IN WC -t <br />Consultant / Sub Contractor__ Address � r c �i /�,' . W, li5,1111 City S i %� ►f r; 'Lic# Iv ' -I 7 PhoneACZ k <br />GIS Coordinates: X Y Township 0 Range c. <br />Section <br />WORK TO BE PERFORMED <br />)'NEW WELL / BORING ( CPT, GEOP HYDROPUNCH HAND -,AUGER <br />'Other: <br />COMMENTS <br />TYPE OF WELL <br />,,,,rONITORING <br />D EXTRACTION <br />D VAPOR <br />D AIR SPARGE <br />D SO BORING # <br />,KW LL# Mw <br />--- <br />IN <br />a FOLLOW STEM <br />D \AIR HAMMER/DRIVEN <br />D MUD ROTARY <br />D PUSH POINT <br />(V <br />0 DESTRUCTION (choose type below) <br />D OVER -BORE <br />0 PRESSURE GROUT <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE MULTIPLE CASINGS? DYES 0 WELL CASING DIA: <br />CASING THICKNESSSca >Scid (AvJz V/ TYPE OF CASING: D STEELL&PVC D OTHER: <br />DEPTH OF GROUT SEAL V1, TREMIE TYPE TO BE USED: JkAUGERS DHOSE <br />GROUT SEAL PUMPED: D Yes ,�grNo (NOTE: MAXIMUM FREE -FALL DEPTH IS 39q,� <br />D SOIL BORING D HAND AUGER APPROX. BORING DEPTH_! 5 F��_ r '}-BOLTED TRAFFIC BOX or D STOVE PIPE <br />D OTHER:_G OTHER CONDUCTOR CASING PROPOSED?_ ( if YES, list specifications here): <br />41) <br />COMMENTS: R Gv£� VL i N0A 7E A <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br />icicuy utniry inai i nave 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 aoent'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." Contractors hiring or sub- <br />contracting signature certifies the following: "1 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 />T E APPLICANT MUST CALL 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />Sicned x J, r Title 1�p�Rct G VIA10 )7 Date MC <br />SEE SITE M P N UNIT IV WORK PLAN DATED.- <br />DEPARTMENT <br />ATED:DEPARTMENT USE ONLY JasZ " <br />Application Accepted By Date Issued W/ ..� 'd / srea d <br />Grout Inspection By Date Final Inspection By Date <br />Destruction Inspection By Date _ 71114Wav <br />COMMENTS / CONDITIONS:_62X_% t;IX4 ---'/i(� �w 23�9st. ZSIDO, 2 <br />ACCOUNTING ONLY: AID# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE ST # INVOICE <br />254�- <br />C-57 LICENSED CONTRACTOR MUST SIGN LICENSE 8-, WORKERS' CO LARATION <br />UNIT IV - 6/23/99 /sign bkpg/MI <br />