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S-23-1999 4:44PN1 FROP-1 P 2 <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION ("PHS-EHO") <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3450 <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 describes. This application is made in compliance with <br /> San Joaquin County Development Tile, Chapter 9-1115.3 and the Standards or San Joaquin County Public Health Services.Environmental Health Civision. <br /> Assessor's I/ CLb C'j <br /> WELL Location. c s� Cross Street] c?/�'' .Cc_-,c 2itY r�1 � �'Z'p -Parcel# (`� <br /> PROPERTY Owner <br /> `iY1i�_i+%Y�r: ACdressr�p'�t> 7 CityZip s % Phone#�5 3C7> 7�;3 66, <br /> �� Address r�c�F'Y' Citylal � { ZP!��1�VonettE��S <br /> C•57 Contra�or <br /> Consultant/Sub Contractor ✓tom Address 37 <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> NEW WELL/BORING CPT, GEOPROS E!HYORCPUNC NO-AUGER. OTHER-) a DESTRUCTION (choose type beio­ <br /> Q SOIL BORING - Q OVER-BORE <br /> UfELL# PRESSURE GRCI.'T <br /> Q <br /> — <br /> CC:MmENTS. <br /> 'YPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFiCAT10NS �'�vi-/�ll� %� x 1,z> H C2 <br /> MONITORING Q HOOSTEM DIA. OF BOREHOLE �f. MUL7tPLE CASINGS'? IYES )(NO WELL CASING <br /> LW <br /> j EXTRACTION Q:,.!t HAMMERJOR!VEN CASING THICKNESS TYPE OF CASING: Q STEEL Q PSC Q OT*tER: <br /> Q VAPOR Q"IUD ROTARY DEPTH OF GROUT SZA i' T REMIE TYP=TO BE USED: )<aUGFRS C,"CSE <br /> AIR SPARGE Q PUSH POINT GROUT SEAL PUMPED: Q Yes Q No (NOit: MAXIMUM FREE-FALL DEP 1r H IS zl0') <br /> Q SOIL BORING HAND AUGER APPROX. BORING DEPTH <br /> ham? Q BOLTED TRAFFIC BOX or Q STOVE?IP. <br /> j GTHER: CONDUCTOR CASING PROPOSED? (if YES, list specificauons here): <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS! <br /> I •nereby certify that I have prepared this application and that the work will tie done in accoredancwrth San Joaquin County Ordinances. State -3ws. and ,< ,as <br /> and Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: "1 certify that in the performance of the worK <br /> fvr which this permit is issue4 I shalt not employ persona subject to WORKMAN'S COMPENSATION Laws of CallfOmia." Contrac:or's hiring or s��- <br /> contracting signature certifies he`,ollowing: "1 c fy chat in the performance of the work for which this permit is issued. 1 shall employ persons subject to <br /> WCRKMAN'S COMPENSATION Laws of Cal' mia.' <br /> THEA P ANT M CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> lr �vitle 7 Date <br /> Signed x <br /> Ti � �• <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED <br /> DEPARTMENT USE ONLY C- <br /> Application Accepted By �1 I <br /> ,�_w/ / �. Date Issued Area �" <br /> - <br /> Grout Inspection By <br /> D e Final Inspection By Date <br /> -Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ___T <br /> FAC# <br /> ACCOUNTING ONLY: AiDll <br /> ?E COOES I FEE INFO AMOUNT REMITTED CHECKWCASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER I iNVOICS <br />