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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., 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, Environ <br /> a sormental <br /> � w �.- <br /> Health Division. <br /> WELL Location6 • Y%oLr4&- 1 Cross Streeg-n-wt>� a-s CityS4oGR 't <br /> � _Zip�5�6 Parcel# <br /> sSCd•G4t ��ityuip4QO�Phne <br /> L-4- <br /> City/4 <br /> PROPERTY owner lt MAddress tio Lic# 6 Phone# SYS�1O0� <br /> C-57 Contracto ?:So yyclG Rmd 0 <br /> M—s is. — <br /> Consultant/Sub ContractorCaMLy-iq k/1 V• Address Q O BMK 2 City_ Lic#b�Z Phone#L g�5'�tSO <br /> GIS Coordinates:X Y ,Township Range Section <br /> WORK TO BE PERFORMED <br /> p NEW WELL I BORING(CPT,GEOPROBE,HYDROPUNCH, AND-AUGER,OTHER-) Q DESTRUCTION(choose type below) <br /> %SOIL BORING#Gp'T- (Of CV-r-/I p OVER-BORE <br /> I]YVELL# Q PRESSURE GROUT <br /> In <br /> *Other:- G OGG C:reS-S QQ�Mda <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING a HOLLOW STEM DIA.OF BOREHOLE Z1/ MULTIPLE CASINGS?a YES`,ANO WELL CASING DIA: <br /> EXTRACTION Q AIR HAMMERIDRIVEN CASING THICKNESS N TYPE OF CASING: 0 STEEL a PVC a OTHER: <br /> EA <br /> 0 VAPOR Q MUD ROTARY DEPTH OF GROUT SL TREMIE TYPE TO BE USED: a AUGERS ;KHOSE <br /> p AIR SPARGE )KUSH POINT GROUT SEAL PUMPED: `&Yes p NS (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> `SOIL BORING p HAND AUGER APPROX.BORING DEPTH 9-S a BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> 0 OTHER:-0 OTHER CONDUCTOR CASING PROPOSED? Ao (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: "l certify that in the performance of the work for which this permit is issued,I shall employ persons subject to <br /> WORKERS' NSAT/ON Laws of California." <br /> ALL E UNIT IV INS EC R 8 WORKING HRS IN ADVANCE FOR ALLRE UIRED INSPECTIONS. <br /> Signed x le/Company <br /> Print Name ( L/ Date <br /> DEPARTMENT USE ONLY / /5/1 / <br /> Application Accepted By r Date Issued 1 6 � Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 1/18/2000 <br />