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WELL PERMIT APPLICATION FORM UNIT IV <br /> RECE��ED ✓ <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES azo <br /> DEC 2 12000 ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> ENVIRONMIIENT HEALTH �i <br /> PERMIT/SERVICES (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �1 <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 Divisio <br /> Assessor's <br /> WELL Location /y/°y..i TrF iti Ho f2s C- Cross Street City Zip Parcel# <br /> PROPERTY Owner Address - City Zip Phone# <br /> C-57 Contractor V-fJ -C�(L LL.IJ4 Address P.O, Bo A' S1 City(f Io \/JS--,4Zip!LC7/Lic# So phone#`1J6 77 1-0 <br /> Consultant/Sub Contractor (f'0. AN o 4 Address/$B' r-,tM/ JV 1dCsrc/C CityS(acK aeric# Phone# -02-2J 'p S/6 <br /> GIS Coordinates:X , Y ,Townships 2S Range Y(!!r Section .3 � <br /> WORK TO BE PERFORMED <br /> NEW WELL I BORING(CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER,OTHER") _ 0-DESTRUCTION(choose type below) <br /> a SOIL BORING# 0 OVER-BORE <br /> 0 WELL# p PRESSURE GROUT <br /> 'Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> VMONITORING KHOLLOW.STEM DIA. OF BOREHOLE S r• MULTIPLE CASINGS?0 YES 0 NO WELL CASING DIA: Z r <br /> U EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS SCH Ko TYPE OF CASING: a STEEL A PVC 0 OTHER: <br /> 0 VAPOR U MUD ROTARY DEPTH OF GROUT SEAL i/ ' TREMIE TYPE TO BE USED: 0 AUGERS (HOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes kNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> p SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or `STOVE PIPE <br /> 0 OTHER:_0 OTHER CONDUCTOR CASING PROPOSED? o (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: "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." 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 Califomia." <br /> THE APPLICANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed x Title Date <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Issued Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE <br /> -1 RP11 <br /> C-57 LICENSED CONTRACTOR MUST SIGN LICENSE &WORKERS' COMPENSATION DECLARATION <br /> UNIT IV- 6/23/99/sign bkpg/MI <br />