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WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES U�llLS V� LSU l/ I. D <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) u <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 MAY 2 4 2002 <br /> (209) 468-3449 <br /> LTH <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENT c�ppC �ttt AWZ <br /> S <br /> kR <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is��7a <br /> San Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br /> ���\ 1 Cl Q Assessor's <br /> WELL LocationC77-0 �' C ��e�--4� Cross StreeF71-1':S4 5 City J'oGL �ziip?67-416 Parcel# <br /> PROPERTY OwnerSke-i' 0:( 1�"� (A d�dress�>-O._%ClX -136 �/ Citty�� 'MZipl Phone le s-1� <br /> C-57 Contractor C7 ���4� Address l ` � Cityq/! - z-Zip�'S�Lic#C54 Phone /4zS 0313'SfiCO <br /> Consultant/Sub ContractoC Mkr-i0. ,&4Q AddressP.a.QOX ZS t City.�O' gLic ,�Phone#� t35'y� % <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED <br /> NEW WELL/BORING CP.T GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) DESTRUCTION(choose type below) <br /> SOIL BORING 4C1PT-S -1,r-QAo%!n= Wr-'1 0 OVER-BORE <br /> Q WELL# PRESSURE GROUT <br /> 'Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Q MONITORING HOLLOW STEM DIA.OF BOREHOLE -Z*7 MULTIPLE CASINGS?a YES "X NO WELL CASING DIA: <br /> 0 EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS_TYPE OF CASING: I1 STEEL I]PVC []OTHER: <br /> 11 VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL 100*' TREMIE TYPE TO BE USED: a AUGERS )*OSE <br /> I7 AIR SPARGE PUSH POINT GROUT SEAL PUMPED: " Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> SOIL BORING p HAND AUGER APPROX.BORING DEPTH 100'0 a BOLTED TRAFFIC BOX or U STOVE PIPE <br /> a OTHER: OTHER CONDUCTOR CASING PROPOSED? AID (if YES, list specifications here): <br /> COMMENTS Grnoc.. --pe-c, OVkkik <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,f shall not employ persons subject to WORKERS'COMPENSATION Laws of California." Contractor's hiring or sub- <br /> contracting signature certifies the following: "/ce that in the performance of the work for which this permit is issued, I shall employ persons subject to <br /> WORKER 'COM NSAT/ON Laws of Califo 'a." <br /> R <br /> A <br /> / LL E UNIT IV INS EC 48 WORKING HRS IN ADVANCE <br /> �FFORRSA ALL�REQ,U�7IREDD,INSPECTIONS. <br /> Signed x / ,/ TitlelCompany / ([/v/ �,1/ c <br /> Print Name Z L I/C I Date <br /> r xu <br /> � DEPARTMENT USE ONLY <br /> Application Accepted By Date Issued /� y Area _y <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 It INVOICE <br /> 5 0 I �`� $ 1 ? - a 300 a <br /> ii>.siz000 <br />