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WEL PERMIT APPLICATION F*M UNIT IV <br /> SA?4 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 1 YEAR FROM DATE ISSUED W <br /> �r tpiiance with <br /> 4ppGntion is hereby made t0 San Joaquin <br /> 9-11f 15.�and the Standards rmit to construct and/or <br /> of San Joaquin county Publstall the work ic Health Service. This ts, Environmental Health Division. <br /> San Joaquin County Developme Assessors <br /> �. .L�sG�o�.'7xlC—Cross Streets . Y City Zip�s320 Parcel# <br /> WELL Loeatiore hone# <br /> PROPERTY Owner /� frl <br /> g '343 <br /> A/ h__ [1 i cin ' l Zp <br /> s. rt. [_Address - •�— &ks�City <br /> �'J'&oou_ 5-57 Contractor d'� �Address!Q?AO�09 <br /> Consultant f Sub Contractor <br /> Address jL��2/g !/ CityB"Lir0i Phone# <br /> Range Section <br /> 31S Coordinates:X , Y <br /> Township <br /> WORK TO BE PERFORMED <br /> � DESTRUCTION(choose type below) <br /> XNEW WELL I BORING(CPT, GEOPROBE,HYDROPUNCH.HAND-AUGER.OTHER-) 0 OVER-BORE <br /> 0 SOIL BORING# 7 0 PRESSURE GROUT <br /> AWELLt- <br /> •Other. G t! <br /> ::OMMENTS: 47' 4r-K. <br /> '`fPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br /> HOLLOW STEM DIA OF BOREHOLE " MULTIPLE CASINGS?0 YES ZNO <br /> WELL CASING OIA:�_ <br /> tMONITORING TYPE OF CASING: 0 STEEL �VC 0 OTHER: <br /> 0 EXTRACTION O AIR HAMMER/ORIVEN CASING THtCKNESS,�_ a <br /> VAPOR 0 MUO ROTARY DEPTH OF GROUT SEAL�` G <br /> D � TREMIE TYPE TO BE USED: 0 AUGERS *OSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED:4Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER APPROX.BORING DEPTH OLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 7� � <br /> CONDUCTOR CASING PROPOSED?_JI&_(if YES.list specifications here): <br /> p OTHER: <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS? <br /> iter or licensed agents signature certifies the following: "/certify that in the performance of the work <br /> ;hereby Certify that I nave prepared this application and that the work will be none in accoroance with San Joaquin County Ordxtancas, State Laws,and ures <br /> and Regulatiorts of the San Joaquin County. Hom: "I cmpeow mons subject to WORKMAN'S COMPENSATION Lsws of California." ConoCtor suiting or <br /> sub- <br /> for which this permit is issued.1 shall not employ p <br /> �ntracting signature certifies the followingertify that in the performance o.'the work for whrcrr this permit is issued. i snail employ persons <br /> A ,owmAMS C lypENSAT10N Laws of C81ddmia.' <br /> AP ICANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> /.�,...�- Date /0—.x5-00 <br /> rate Gs� <br /> Signed x <br /> SEE S[ E MAP 7=wW�PLAN. DATED oI — <br /> DEPARTMENT USE ONLY J <br /> IDate Issued l I 1 Q 0 Area <br /> Application Accepted BY ��'`_ Date <br /> Date Final Inspection By <br /> Srout Inspection By Date <br /> Destruction Inspection By <br /> COMMENTS/CONDITIONS: <br /> I FAC# <br /> I <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#lCASH RECEIVED BY DATE I PERMITISERVICE REQUEST NUMBER INVOICE <br /> UNIT IY-5/99/MI <br />