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WELL PERMIT APPLICATION FORM <br />SAI`} JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION ("PHS-EHO") <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3450 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR =ROM DATE ISSUED <br />UNIT IV <br />Aoplication is hereby <br />made to San Joaquin County for a permit to construct and/or install the work descrtbed. This application is mace in compliance with <br />San Joaquin County Development i die. Chapter 9-1115.3 and the Starwan3s of San Joaquin County Public Health Services, Environmental Health Division. <br />Assessor's <br />/ Street city GvZ Z 1r L lir r-� Cross reer� t i� bio 'r' w Lr Parcel# <br />7 �- <br />WEL_ Location <br />?hone*Z� <br />?ROPERTY Owner <br />y✓�' <br />1)i.i biri il`� iel^Ylc` Address 5AIM-fir- City Zip <br />! /C� c �iS ���- Ztpc�.5%/ Lim %'ya'� Phone# 9ld -777- y/ttri <br />Ci <br />-57 Contracor t Address city — <br />t ��n <br />Address ij�xZ Cay Sh��h"UGfi+ Phone# zt�i ��- 36ZC <br />Consultant! Sub Contractor([.. <br />df f��°` <br />,IS Coordinates: X <br />Y Township Range Section <br />'NCRK TO BE PERFORMED <br />WEL ' BORING ( CPT. GEOPROBE. HYDROPUNCH. HAND -AUGER. OTHER-) Q DESTRUCTION (choose type below) <br />] `EW <br />Q SOIL BORING = [] OVER -BORE <br />PRESSURE GROUT <br />'Cther: <br />CCMMENTS: <br />-"PE OF'NEL-' <br />CCNS7RUCTICN TYPE CONSTrRUCT10N SPECIFICATIONS <br />j;'•:1CNITORING <br />M DIA. OF BCROt E MUL-iPiLE CASINGS? Q YES 13 -NO WELL! CASING DIA: <br />(j HOLLOW S i =E.H <br />]=XTRACTiON <br />] AIR ! AMMER/ORIVEN CASING iICKNEj � qL -YP= 'OF CASING: 0 STEEEL "0'PVC Q OTHER: <br />] wUD ROTARY DEPTH OF GROUT SEAL --1 7 -REMIE TYPE 70 3E USED: ©"AUGERS ]HCSE <br />VAPOR <br />AIR SPARGE <br />Q PUSH POINT GROUT SEAL RUMPED: ,] `.'es ANo (NOTE: MAXIMUM FREE -FALL DEPTH IS 3 <br />] <br />Q SOIL BORING <br />D ti- AFFIC 30X or Q STOVE ?IP= <br />Q HAND AUGER APPROX. 3CRING DEPTH. I2 % p�BOL i — <br />] OTHER: <br />CONDUCTOR CASING PROPOSED /` ( if YES. list specifications nere): <br />' <br />,:�• aC, p-��'�r1»ilii Y ��- _h <br />CCMMEN TT S: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS? <br />nereoy certify that I have prepared this application ano that :tie wont will oe oone in ac-.oraance wrtn San Joaquin Gounry ordinances, <br />3na Regulations of the San Joaourn County. Homeowner or !icensea agent's signature certifies the ;allowing: "I certify that in the performance of the work - <br />`or wnicn this permit is issued, I snail not employ persons suolec: to .1ORYh1AN'S COMPE'dSA77ON Laws of California." Contractor's niring or sub- <br />:ontracting signature certifies the following: 'I certify that in the performance of the worst for wnicn ✓,his permit is issued. I snail employ persons suoject to <br />'NORKMAN'S COMPENSATION Laws of California.' <br />THE APPU�ANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />LlG'� w tle �' <br />Signed x <br />SEE SITE MAP UNIT IV WORK PLAN. DATED <br />DEPARTMENT USE ONLY ( q O (L <br />application Accepted By <br />Date Issued "' �� ( ` � O Area <br />Grout Inspection By <br />Date Final Inspection By Date <br />Destruction Inspection 3v Date <br />COMMENTS / CONDITIONS: 3 62 <br />ACCOUNTING ONLY: AID# <br />PE CODES I FE= INFO I AMOUNT REMITT'cD CHECK»lCASH I RECEIVED BY IDA 'c PE NUM <br />T BER INVOICE <br />i <br />iso o ! Mwl ! I I C'► ib j 02.3 ec = <br />UNIT IV - x/99 /MZ <br />