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WELL PERMIT APPLICATION FJRM 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 <br /> 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br /> WELL Location (MQ, a Assessor's <br /> Cross Street City C e- Zip Parcel# I3V�15� <br /> PROPERTY Owner Address,2�D 7 : <br /> �G,"" City � Zip�S � Phone#���-�'—�.�� <br /> C-57 Contractor %``�'(/ Adddrr'ess 3y��rf,C/7,,'1//sl��L//}�'LC��// //,city <br /> S�i Zip Lic# V LPhone04-).3�23 222L <br /> Consultant/Sub Contractor GeV Address-/Gt"/rl),ox'/�//ity t;rz Lic# Phone# <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> 0 NEW WELL/BORING(CPTG OPROBE, HYDROPUNCH,HAND-AUGER,OTHER`) 0 DESTRUCTION(choose type below) <br /> OIL BORING# 0 OVER-BORE <br /> 0 WELL# 0 PRESSURE GROUT <br /> 'Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORINGHOLLOW STEM DIA.OF BOREHOLE • ZS MULTIPLE CASINGS?0 YES 0 NO WELL CASING DIA: —" <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL D TREMIE TYPE TO BE USED: 0 AUGERS OHOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes �&io (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH `7 <br /> 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER:_0 OTHER 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: '7 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, I shall employ persons subject to <br /> WORKERS'COMPENSATION Laws of California." <br /> T PP,LICA UST C LL 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSP CTIONS. <br /> Signed x Title f/l ' Date 3 <br /> SEE SITE MAP IN NIT IV WORK PLAN DATED: Z,Lee) <br /> DEPARTMENT USE ONLY <br /> Application Accepted By (tel r�A �� Date Issued 3--7-00 Area <br /> Grout Inspection By Date Final Inspection By Date 3 ' O0 <br /> Destruction Inspection By Date -7- 06Zai L_c�P <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FArtt <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PER�fWSERVJeE REQUEST# INVOICE <br /> 3SU] �R 2 L CO /-7 9R# 00 aX1 92b <br /> C-57 LICENSED CONTRACTOR MUST SIGN LICENSE&WORKERS' COMPENSATION DECLARATION <br /> UNIT IV-6/23/99/sign bkpg/MI <br />