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WELL PERMIT APPLICATION FORM UNIT IV <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD ORIGINAL <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 County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />n ` 'I ,car• Assessor's <br />WELL Location cal �� �_her CKC4- Cross StreetLVAve City Lo citt ,Zip r'�`� 7t✓ Parcel# ��3 `-430'",,3 <br />PROPERTY (Dwnertl('hf V i f'lnf:Sf'Pl Address ne, - it. City L Vel CAI. ZipU -Phone# '368-53)l <br />+ r If r� '/ <br />C-57 Contractor Czirik'�'-,G L+d . Addressf 930 Ver op 9f, SV �ity ' t I ZipT�%Lic# Phone#,JC` 7o;,6 r�9-Z <br />Consultant / Sub Contra ctor5T43keA 6 fl of f'' Address P.''�� City D pi� tic# -75jJ-C 1. <br />GIS Coordinates: X Y Township 3 / n1t Range 7E Section <br />WORK TO BE PERFORMED: <br />NEW WELL / BORING ( CPT GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) <br />SOIL BORING # <br />[] WELL # <br />"Other: <br />[] DESTRUCTION (choose type below) <br />[] OVER -BORE <br />[] PRESSURE GROUT <br />COMMENTS: p <br />TYPE OF WELL <br />INSTALLATION TYPE <br />[] MONITORING <br />ff HOLLOW STEM <br />[] EXTRACTION <br />[j AIR HAMMER/DRIVEN <br />(J VAPOR <br />[] MUD ROTARY <br />[] AIR SPARGE <br />[] PUSH POINT <br />' SOIL BORING <br />[] HAND AUGER <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE 9 MULTIPLE CASINGS? [] YES [] NO WELL CASING DIA: <br />CASING THICKNESS TYPE OF CASING: [] STEEL [] PVC [] OTHER: <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: [] AUGERS []HOSE <br />GROUT SEAL PUMPED: [] Yes jl No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />APPROX. BORING DEPTH 35 4 - ! CO i [] BOLTED TRAFFIC BOX or []STOVEPIPE <br />[] OTHER: [] OTHER CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br />COMME <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: '7 certify that in the performance of the work <br />for which this permit is issued,/ shall not employ persons subject to WORKERS' COMPENSATION Laws of California." Contractor's hiring or sub- <br />contracting signature certifies the following: "1 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 U ('D 11�r �fh, 1eG L1A I <br />1 1 0 <br />Print Nam -J D � Y%� , Hf� rf` Z 3 C� % Date p �' � �'' 4/ <br />SITE FILE ADDRES,$/WORK PLAN DATE: <br />Application Accepted By_ <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS / CONDITIONS: <br />Date <br />Date Issued—u7-. <br />Final Inspection By <br />Area - '°- " <br />Date <br />ACCOUNTING ONLY: AID# <br />PE CODES <br />FLEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />P VIC REQUE VOICE <br />SZ7 <br />6LJ <br />C-57 exp._ WC/waiver_ C-�7 Letter of Authoridtion to sign permit-€r�cr�ashmen+ �- f5�` 5/17/00 <br />�vl <br />