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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., 95242 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> �OWl <br /> piication s hereby made to San Joaquin County for a permit to construct arot install the work described. This application is made in comoliance with <br /> tan Joaoum County Development Title.Chapter 8-1115.3 and the Standards of San Joaquin County Public Health Services. �rivi assessor s nmentai ealth Division. <br /> /° ! Cross Street City Zip 3 ?3rcelst <br /> WELL Location � 4 r1L1�i2� A S� - V-r <br /> I�I ICF31•S�At2h I {"I V A�" 4SG S:: C;ty S-TQG!—LO�?ioq honeft �`' s3 <br /> dtlress /� <br /> RQ0PERTY Owner�y� �------ �n,� <br /> lj l� Address Z3 111 -. A1t.1 D4o:ty�,lv <br /> 6 P, �t Lic � �0�6neft <br /> C 57�ontrac:or ,..A/ <br /> C`onsuitant/Sub Contractor 3 <br /> J !_ L 11�x 1g )�793 Qnnnu .ty d� Uc�t �--''hene .� �T73 8 <br /> Y � , Township Range Section <br /> GIS:.Dorainates:X — - <br /> 'NCaK 'O BE PERFORMED <br /> Q DESTRUCTION(choose type below) <br /> Q NEW WELL BORIN CPT, EOPROBE. HYOROPUNCH, HANO-AUGER.OTHER-) p OVER-SORE <br /> Q SOIL BORING» LL.S Q PRESSURE GROUT <br /> Q WELL <br /> t,Js'ivts 5 ( uv <br /> COMMENTS- <br /> j.�PG O�L INST LLATION 7YP_ CONSTRUCTION SPECiFiCATIONS <br /> OLLOW STEM DIA.OF 3CREN.OLE_�_,.MULTIPLE CASINGS?Q YES Q NO WELL CASING DIA <br /> (I 4MONITCRING TYPE OF CASING: Q STeEL Q PVC Q OTHER: <br /> 0 -cX''RAC710N Q AIR HA.MMERlDRIVEN CASING THICKNESS�� � AUGERS <br /> VAPOR MUD ROTARY OSE <br /> DEPTH OF GROUT SEAL L 2 TREMIE TYPE TO BE USED- Q <br /> J AIR SPARGE Q PUSH POINT GROUT SEAL PUMPED: Q des 0,4o (NOTEIMUM FREE-FALL DEPTH IS 50 <br /> HAND AUGER APPROX. BORING DEPTH S t OLiED TRAFFIC BOX or Q STOVE PIPE <br /> OIL BORING Q � f YES. list soec:ricauons here): <br /> r)HER Pg OTHER CONDUCTOR CASING PROPOSED. 1�1 D c <br /> pm <br /> v1ntIEN I <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> eraoy certify that I have prepared this application and that the work will be done m accordance with San Joaauin County Orninences, State Laws. and Rules <br /> �d Peguiations of the San Joaquin County. -iomeowner or!icensed agent's signature certifies the following: "f cartify that in the performance of the work <br /> r which this permit is issued.I shall not employ persons subject to WORKERS'COMPENSATTON !$issued.s ol Jf johal!?mR1QYlractor s Rarsons sub e�ring o"0 b <br /> g: • !hat in the performance of the work!ar which this pe <br /> rmtt antrading signature certifies the foilowin /comfy <br /> °✓CRKERSZCONSA TION L Is of alifomb." <br /> THE LI T MUS ALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIO S. <br /> I/ 1 <br /> 711'17 7 <br /> itle <br /> `:ign9d x <br /> SSE SITE MIA IN UNIT IV WORK PLAN DATE <br /> DEPARTMENT USE ONLY <br /> Date Issued — — <br /> A=Iication Accepted By i �y —/ 3 <br /> �r^{?wo F� In3piecchsa t B <br /> Grout inspection 8y .h w''/fZw Yu� �7_1 �i7 — » �1J �C 7�l3(r!� <br /> Destruction inspection 8v <br /> � <br /> CCAitMENTw -CONDITI lei <br /> - FACx <br /> ACCOUNTI�GOY: AID# <br /> PE CODES I FEE INFO AMOUNT REMITTED NECK JCASH RECEIVED BY DATE I PERMITJ9ERVICE REQUEST NUMBER INVOICE- . <br /> 1/r Q'1 Y d7� - > <br /> 3/ S/ �J <br /> C-;7 LICENSED CON-rF-ICTOR.MUST SIGN LICENSE t�WOItKERF"COMM' iSATION DECLkR.�TION _, c:. <br /> UNIT ZV- 6/23/99 /sign bkpg,-" � <br />