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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 /> <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 )- 1 0 E , Mit/Int ir 5 1. . Cross Street )(4 -1-' (Cl 4v-, City Pio I'l 1 C ot Zip Parcel# <br />PROPERTY Owner 6- ,1 / c{ Mu 14 14 C lk Address 10 0 I l/VI i C.,4),,, )I,. city kd 4. C ,1 Zip 9 C Phone# S;i i-; --,30 <br />( <br />5— <br />.1 <br />C-57 Contractor /i4vdti(4ci (.2•4) Fin vi Yo'AieAtdidaress 110 0 $- W. w Iillfc Viol City 5114 vl Zip 9 '1 •i) ).-Lic# 64024 7 Phone# 14 ‘ 7- ioo 6 <br />..._.) <br />Consultant / Sub Contractor C MA 4 Address City Lic# Phone# <br />GIS Coordinates: X y ,Township Range Section <br />WORK TO BE PERFORMED <br />It NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />15 SOIL BORING # -3' <br />0 WELL # <br />0 DESTRUCTION (choose type below) <br />0 OVER-BORE <br />0 PRESSURE GROUT <br />*Other: <br />COMMENTS: 5 R v <br /> <br />?11 ,,\ Da i-cf 7- 1 JaimActrx k)00 <br />\-11 <br />TYPE OF WELL INSTALLATION TYPE <br />O MONITORING 0 HOLLOW STEM <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN <br />0 VAPOR a MUD ROTARY <br />0 AIR SPARGE 'PUSH POINT <br />SOIL BORING 0 HAND AUGER <br />0 OTHER: 0 OTHER <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE 7 MULTIPLE CASINGS? 0 YES fj NO WELL CASING DIA: <br />CASING THICKNESS ht//lt TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />DEPTH OF GROUT SEAL T P TREMIE TYPE TO BE USED: 0 AUGERS OHOSE <br />GROUT SEAL PUMPED: U Yes No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />APPROX. BORING DEPTH 2. i7 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? Iv/A ( 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: "/ 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: "/ 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 />CALL THE UNIT IV INSPECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />Print Name <br />V11444jt4 Title/Company 6 'c1l /\ <br />601/4 10 Date VI /C C <br />SEE SITE MAP IN UNIT IV WORK PLAN DATED: /2, t/o <br />G ,so t,t Vi)v1 Signed x <br />Application Accepted By Com: i-t-t.A.Aret <br />Grout Inspection By LA›.-vv.4 c <br />Destruction Inspection By <br />DEPARTMENT USE ONLY <br />Date Issued <br />Date 3(2—c9 [00 Final Inspection By <br />Date <br />Area <br />Date <br />3 10- to <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# <br />_ FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE - -' •' ' • 1.< # INVOICE <br />3 SD t tA1151 c<ci . 0 o I 2-1 ° 7-3 1\( -V) 460 sR# 0 0 a;-15S -' <br />18/2000