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WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICE <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD; <br /> 304 E. Weber, Third Floor, Stockton, CA., 9'5202 F.1 OPY <br /> (209)468-3449 <br /> : .r <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/qr 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.Environmental Health Division. <br /> ��4///�J E.1,�„/___ Y -/ /ri li ';01- <br /> ;p2 Assessor's fr10 / <br /> WELL Location �Gf� '��(J�'�Cross St erq t City ��b Zip ! Parcel#/ 'pC / <br /> i lI Address <br /> � p SWZ Ph�#(�rf� ! 7-if <br /> PROPERTY Owner C��'7 0�l�%u-ff7�� Address.bSl�!_ 6'Z.t�?s�/�a Cit �✓ Zi 3 <br /> C-57 Contractor �{ IA'ddres Yll6l F.+7C�-�lri'Yc'1 20r City6 Zip9% Lic# Phone l <br /> Consultant/Sub Contractorgkd&_42r7 Addresso �4:,l Phone�`1111�r-H/! � <br /> GIS Coordinates: X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> Q NEW WELL!BORING (CPT, GEOPROBE, HYOROPUN H, HAND-AUGER,OTHER-) (DESTRUCTION(choose type below) <br /> SOIL BORING# $&,-jRj1vy Az"-4r7117- a OVER-BORE <br /> 'Other. U WELL;; a PRESSURE GROUT <br /> COMMENTS. <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING HOLLOW STEM DIA.OF BOREHOLE 8-/d v MULTIPLE CASINGS?0 YES J(NO WELL CASING DIA.AJ4 <br /> Q EXTRACTION o AIR HAMMER/DRIVEN CASING THICKNESS NA TYPE OF CASING: o STEEL []PVC 9 OTHER: <br /> Q VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS OHOSE <br /> a AIR SPARGE a PUSH POINT GROUT SEAL PUMPED: 0 Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING Q HAND AUGER APPROX. BORING DEPTH 'PO r a BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> a OTHER:_G OTHER CONDUCTOR CASING PROPOSED? AJ (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 thatin the performance of the work <br /> for which this permit is issued,1 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, /shall employ persons subject to <br /> WORKERS'COMPENSATION Laws of Califomia.' <br /> HE APPLICANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS./meq <br /> Signed x TitleDates/ r/ <br /> SE SITE MA UNIT IV WORK PLAN DATED <br /> DEPARTMENT USE ONLY g <br /> Application Accepted By Date Issued / Are <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> FAC# <br /> I <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH REC ED BY DAIE PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> ZD , AA <br /> C-57 LICE <br /> UNIT IV- 6/23/99/sign bkpg/MI <br />