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POW, <br /> WELL PERMIT APPLICATION FORM UNIT N <br /> SAID JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION ("PHS-EHD") <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3450 <br /> NON-REFUNDABLE PERMIT EXPIRES i 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, Environmental Health Division. <br /> r Assessors <br /> At <br /> WELL Location 70 b 14 - k 4 P0I _5Z- Cross Street �a r �� S L City o C U ✓l Zip q 5 1 0 �- Parcel# <br /> PROPERTY Owner 2✓1 S 5 E/i o i"G _Address 706 lU L Do o t 0 City 5)� V1 ZipQ S XC Phone# `� 5 %6 ' T <br /> i�3 �5� 7 `r <br /> ga16 <br /> La I IV>v (, o G� � ;Iq 'o-Address 5u 9 FEEL' (t 5 UIVc� City 1�o5• VX� ?ip 50 +aCt�Phone# 3�4 <br /> ;;-57 Contractor + <br /> ddress <br /> (,- FN V;�.'�'C�aA �ioCy IU �s Iso.tWuY CitOt.0 ii T0-1 Lid �i0 x 7Phone# 7 ' l�G' <br /> ;consultant I Sub Contractor Ad v'ay r° o <br /> 7 Y Township Range Section <br /> GIS Coordinates:X <br /> WORK TO BE PERFORMED <br /> [j DESTRUCTION (choose type below) <br /> Z,,,4–,W WELL I BORING ( CPT.GEOPROBE.i[YDROPUNCH, HAND AUGEr"2.OTHER") Q OVER-BORE <br /> {] SOIL BORING# Q PRESSURE GROUT <br /> g WELL w <br /> 'Other. <br /> ��MMENTS: ,r <br /> Ypc� O� r yyEt_ CONSTRUC i ION TYPE CONSTRUCTION SPECIFICATIONS r <br /> s c DIA OF BOREHOLE�rr _MULTIPLE CASINGS?0 YES 8 NO WELL CASING DIA: r' <br /> .J(MONITORING IHOL_OW S _M c PVC 0 OTHErP <br /> ] ;JCTRACTION t7 AIR HAMMER1DRiVEN CASING THICKNESS 5cl . O TYP� OF CASING: �j STE.L <br /> VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL i REMI---TYPE TO BE USED: Q AUGERS QriCS= <br /> ] .AIR SPARGE 0 PUSH POINT GROUT SEAL?LIMPED: Yes 0 No (NOTE: MAXIMUMJ&BTED TRAr' IFREE-FALL <br /> C BOX orO STOVE PIPE <br /> SOIL BORING Q HAND AUGER APPROX. BORING DEPTH <br /> OTHER: <br /> CONDUCTOR CASING PROPOSED �L {if YES.lis:spec fications here): <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS? <br /> nereby ceniry that I have prepared this application anc;hat the wont will be cone sn accordance 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: l certify that in the performance of the worx <br /> for which this permit is issued.l shall not employ persons subject to WORKMAN'S COMP ,his permit <br /> Laws of California." y persons subject toContractors-hiring <br /> contracting signature certifies;he ioliowing: 'l certify that in the aerformance of the work for whia`t this perm+t rs issued. !incl!employ p 1 <br /> WORKMAN'S COMPENSA;!ON taws of Califomra.' <br /> THE APPLICANT MUST CALL.48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> i file <br /> j�ra ��� �dto t51 Date <br /> Signed z <br /> SEE SITE MAP 1N UNIT 1V WORK PLAN. DATED <br /> DEPARTMENT USE ONLY �� <br /> Date Issued f Area <br /> Apoiication Accepted Sy �' =rna1 Inspection By Date—�` <br /> Date G <br /> Grout Inspection By / <br /> Destruction Insoection By <br /> Date <br /> COMMENTS f CONDITIONS: ` <br /> IAC# <br /> ACCOUNTING ONLY: I AID# <br /> PE CODES FEE INFO AMOUNT REfi4 TTED CHEOKt9CASH I RECEIVED 13Y DATE 1 P1wRMIT1SERVIGE REQUEST NUMBER l lNVO1C <br /> I 1 <br /> o� S6 -oo 251giloril I! 6 <br /> UNIT TV- 5/99/MT <br />