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WELL PERMIT APPLICATION FORM <br /> 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 />Assessors <br />WELL Location.:34 2-S --r)--4,..N( la( oci • Cross Street City .TI-cLC..y Zip Parcel# <br />PROPERTY OwnerCe4 ‘..41eir-r-;5ciS Address SO. T:3ox cityrAe-o-icrAL ziP (5= f Phone#(.556 <br />C-57 ContractorCre....Z ff-4.S.14. Address t::3 . City /44%.141•12Zi6?tiSSii Lic#CS0c4Phone# OZS) -S8CX> <br />Consultant / Sub Contractoi61.4.t-ict. It; ;roqi......4ddress -.14C) City....5=.4c,re1Ck. Lic# Phonef4-40t ct <br />GIS Coordinates: X Y Township Range Section <br />WORK TO BE PERFORMED <br />0 NEW WELL / BORING ( CPT, GEOPROBE, HYDROPU5ICH, HAND5UGER, OTHER') 0 DESTRUCTION (choose type below) <br />.SOIL BORING # 1 i] OVER-BORE <br />0 WELL # a PRESSURE GROUT <br />-Other: <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE <br />O MONITORING fl HOLLOW STEM <br />JJ EXTRACTION 0 AIR HAMMER/DRIVEN <br />Li VAPOR 0 MUD ROTARY <br />AIR SPARGE Igpusri POINT <br />31¢0IL BORING (1 HAND AUGER <br />0 OTHER fl OTHER <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE " MULTIPLE CASINGS? a YES a NO WELL CASING DIA: Ni°1 <br />CASING THICKNESS /V TYPE OF CASING: 0 STEEL 0 PVC B OTHER: <br />DEPTH OF GROUT SEAL 100 TREMIE TYPE TO BE USED: 0 AUGERS ['HOSE „, <br />GROUT SEAL PUMPED: Yes No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />APPROX. BORING DEPTH 100 1:1 BOLTED TRAFFIC BOX or fl STOVE PIPE <br />CONDUCTOR CASING PROPOSED? NO ( 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: I certify that in the performance of the work for which this permit is issued, (shall employ persons subject to <br />WORKERS' COMPENSATION Laws of California." <br />CALL THE UNIT IV INSPECTOR 48 WORKING HRS IN ADVANCE FOR ALLREQUIRED INSPECTIONS. <br /> Title/Company 54q-PP <br />Date <br />Signed x <br />Print Name /Vic? Mr") <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />DEPARTMENT USE ONLY <br />Date Issued I 2-//9/61 <br /> <br />Area LOP <br />Daterai 0 I Final Inspection By Date <br />Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# LAC* <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PErFIMIT / SERVICE ST # INVOICE <br />35-.0i FT- n- I -97 (444. RH sR# 06dy 3?-3 <br />. - .____