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DATE REC'D BY <br />AID# <br />AMOUNT REMITTED CHECK # PERMIT I SERVICE REQUEST # <br />PE CODES <br />ACCOUNTING ONLY: <br />FEE INFO <br />3o <br />INVOICE <br />r,C/10- te <br />Date <br />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 />Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with <br />Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division <br />Assessor's <br />Zip (L 3s Zip WO d2-1 <br />C-57 Contractor rAse-1/4% tysv ‘eeci. c,e1. Address 349 SNA"-Nr Picicx city ValIf4 SirimAcip sS c#gS Phone# (201j772.-0>C3 <br />Consultant / Sub Contractor ATc. S S.L<,‘ ea. LS kV< Address Lug*. c'0.1,wk A.e.1 g. City tileckr--4o Lick Phone# (.20:6s)9 -2,zz,f <br />Township t P4 Range 4 E Section LC) <br />WORK TO BE PERFORMED <br />yi NEW WELL / BORING ( CPT tEOPILBE), HYDROPUNCH, HAND-AUGER, OTHER") <br />0 SOIL BORING # $611 ‘.....4-tisasIn SAO Li <br />fl WELL # <br />0 DESTRUCTION (choose type t elow) <br />0 OVER-BORE <br />O PRESSURE GROUT <br /> <br />*Other: <br /> <br />COMMENTS: <br /> <br />Application is hereby made to San <br />San Joaquin County Development <br />WELL Location 2.4c3 uu• Cross Street'''.Ili*. Lcis c. City Sted.-11-1.3 <br />PROPERTY Owner-rale.ric) tvw.., Address t.ci• ae„K s Zip cIS CI 1ZPhone# (z09.) City tScakto <br />GIS Coordinates X <br />TYPE OF WELL INSTALLATION TYPE <br />0 MONITORING 0 HOLLOW STEM <br />G EXTRACTION 0 AIR HAMMER/DRIVEN <br />0 VAPOR 0 MUD ROTARY <br />0 AIR SPARGE )(PUSH POINT <br />*OIL BORING 0 HAND AUGER <br />0 OTHER: 0 OTHER <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE 2 MULTIPLE CASINGS? Q YES U NO WELL CASING DIA . <br />CASING THICKNESS au r Ar- TYPE OF CASING: 0 STEEL [3 PVC Q OTHER: <br />DEPTH OF GROUT SEAL 1Z -242 C TREMIE TYPE TO BE USED: fl AUGERS [IHOSE <br />GROUT SEAL PUMPED: 0 Yes No (NOTE: MAXIMUM FREE-FALL DEPTH IS 34,,C, <br />APPROX. BORING DEPTH 12 4-ea 1.4. 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( 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: <br />"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." <br />Contractor's hiring or sub- <br />contracting signature certifies the following: "I <br />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." CALL THE UNIT IV INSPECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />Title/Company pri-c_. A • <br />je' ,cASVM__ k 0 r/V)-el Date 101(100 <br /> <br />SEE SITE MAP IN UNIT IV WORK PLAN DATED: <br />..._ . .. . <br />DEPARTMENT USE ONLY <br />Date Issued NO I./ <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS / CONDITIONS: <br />Signed x <br />Print Name <br />C . ) <br />Final Inspection By <br />-7-) 2000 Area <br />Date