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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 <br />San Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />Assessor's <br />WELL Location 2151 Covnir2Y CLAA; 60-V IJ Cross Street j:QANILLLN AdFCity Zip °9S72G`-1 Parcel# /23(D9b30 <br />PROPERTY Owner _j��A N 9PAV-k y; Address -7-11, 1 Ca,W-y QN( Cw?. City :STC Lr t>^N ZipPhone#_C2o-t) c1i,b- 2715 <br />,2P,1vcNc+ <br />C-57 Contractor CA` c:ADE Di iLLZNC Address 36;2. CMEC CLF -CI -F- CityCo20G1A Zip0i--t42Lic#717'g1c Phone#;X-111.c1 <br />,N04ANcEn G EC - <br />Consultant/ Sub Contractor Address 37l S Hpsw 'R+1-1. City 5-pcy,-Tr- Lic# Phone# <br />GIS Coordinates: X Y Township Range Section <br />WORK TO BE PERFORMED <br />NEW WELL/ BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) 0 DESTRUCTION (choose type below) <br />0 SOIL BORING # 0 OVER -BORE <br />-S. <br />'Other: <br />SWELL # M W -17S.. <br />7&{ M W- I` M W -1(� 0 PRESSURE GROUT <br />PE CODES <br />FEE INFO <br />' <br />CHECK # <br />COMMENTS: 1ZCFEREraCE/a.TT,ACl-1P <br />i1 <br />�JoRK- P L -INN DA- EL 15 TAN,)AF,Y ZQ cC <br />INVOICE <br />TYPE OF WELL <br />INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS <br />OSO(o5 <br />-RMONITORING <br />HOLLOW STEM <br />DIA. OF BOREHOLES " MULTIPLE CASINGS?;&YES 0 NO WELL CASING DIA: 2J- <br />0 EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />CASING THICKNESS4y TYPE OF CASING: 0 STEEL XPVC 0 OTHER: <br />O VAPOR <br />0 MUD ROTARY <br />DEPTH OF GROUT SEAL I� S �t35C� TREMIE TYPE TO BE USED: 'AUGERS OHOSE <br />0 AIR SPARGE <br />0 PUSH POINT <br />GROUT SEAL PUMPED: gYes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING <br />0 HAND AUGER <br />APPROX. BORING DEPTH 50 Amo So (BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />0 OTHER:_0 <br />OTHER <br />CONDUCTOR CASING PROPOSED? �A P, ( 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 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 ^�—.�;�' Title/Company STAFF cc T FNrr ST /A1wANC-EO r=Ea1=NL-TP-TP-% NT -AL - <br />Print Name LEE Date .2 I ? 3 1 U 1 <br />SEE SITE MAP IN UNIT IV WORK PLAN DATED: <br />DEPARTMENT USE ONLY <br />Application Accepted By Date Issued <br />Grout Inspection By Date Final Inspection B <br />Destruction Inspection By <br />COMMENTS I CONDITIONS: <br />Date <br />area o6�� <br />Date (/ • Zo • 0� <br />ACCOUNTING ONLY: <br />AID# <br />FAC <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PERM EST # <br />INVOICE <br />252�� <br />2-2,3 <br />OSO(o5 <br />1/18/2000 <br />