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WELL PERMIT APPLICATION FORM UNIT IV <br /> UE <br /> SAID}JOAQUIN COUNTY PUBLIC HEALTH SERVICES AL <br /> ENVIRONMENTAL HEALTH DIVISION ("PHS-EH-0"11`{ , <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 - 1 <br /> l: 3g <br /> (209) 468-3450 <br /> A� <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED A't <br /> Aum, O <br /> Aoplication 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 h` <br /> San Joaquin County Development T'ft Chapter 9-11^115.3 and the Standards of San Joaquin County Public Health Services. Environmental Health Division. <br /> /+ C�k.4 cross street �""j - City 9n"`"�p ¢� Assessors <br /> WELL Location `'7if)7( / Cc Gt�L1• ��l Parcel# <br /> PROPERTY Owner'/^_Ali.d (doe✓eYY I `� Address Ste- City 4 I // Zip Phone#la-//gf � <br /> 57 Contractor V Y V Address &� �� City ,a U%51r-Zipgl57/ Lim 7Mf01 Phones!1/6-777- 9'"o <br /> Consultant/Sub Contractor /�JAddress � Cay s�C��Lic:41/75 Phone# � 771 30 <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> VEW WELL,,BORING(CPT.GEOPROBE HYOROPUNCH.HAND-AUGER.OTHER') G DESTRUCTION(choose type below) <br /> G SOIL BORING;: OVER-80RE <br /> ,�: G PRESSURE GROUT <br /> 'Other. <br /> COMMENTS: <br /> "'PE OF WELL CONS T RUCT10N i YPE CONSTRUCTION SPECIFICATIONS <br /> ,1AONITORING HOLLOW ST�-M DIA.OF BOREHOLE / MUL"nPLE CASINGS?G YES WNO WELL CASING DIA:Z <br /> ((a =XTRACTiON 0 AIR HAMMERIORIVEN CASING.HICKNESSQ TYPE OF CASING: Q STEEL J'PVC 0 OTHER <br /> G VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL f 2� -REmtE TYPE TO 3E USED: 'AUGERS GHCSE <br /> 0 AIR SPARGE G PUSH POINT GROUT SEAL.PUMPED: G Yes No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301 <br /> 0 "SOIL BORING 0 HAND AUGER APPROX.30RING DEPTH z _�30LTED r C 3OX or G STOVE PIP= <br /> 0 OTHER: CONOUCTOR CASING PROPOSED'). if YES.list specifications here): <br /> COMMENTS: 5,ee- <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS! <br /> i hereby certify that I have prepared this application and that the wont will be oone in accoroance with San Joaquin County Ordinances.State Laws.and Ruies <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,l shall not employ persons subject to WORKMAN'S COMPENSA7 0M Laws of California." Contractoes hiring or sub- <br /> contracting signature certifies the following:"I cer*that in the performance of Me work for w"Cn this pwmit is issued I snail employ persons subject to <br /> ,NORKMAN-S COMPEVSA77ON Caws of Calitomia.' <br /> T E APPU NT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED <br /> �INSPECTIONS- <br /> Signed x <br /> l � � �,��.,w-- Tale <br /> SEE SITE MAP UNIT IV WORK PLAN. DATED <br /> DEPARTMENT USE ONLY <br /> ate Issued Oa <br /> Apolitation Accepted By D �+b <br /> Grout Inspection By Date Final inspection By <br /> Armomm <br /> Destruction Inspection By Date" , <br /> COMMENTS I CONDITIONS: (v 3 6�i <br /> rA <br /> ACCOUNTING ONLY: I AIS <br /> PE CODES FEE INFO f AMOUNT REMITTED CHECK#lCASH RECEIVED BY I DAinn PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> iso f I / I G I b .Z <br /> 002-:310E <br /> UN17IV-5/99/MI <br />