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WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <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 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 <br /> Health-I Division. <br /> T7 (` /��� Y"If.Y city lr Zip ParceWt Oq"1'46�f'- (g <br /> WELL Location ("15 1 Cac:%T1 C� -�1r'-�vL • Cross Street <br /> It lu ddress P•0. Box -7869 city &rbZYA zip 1501 Phone# <br /> PROPERTY Owner �lO� �` � �r� , I p � 1J��,�-lv,/y q� (9?��313 -5800 <br /> C-57 Contractor y/r I III Address 750 iH- I�OI• City� ��++ZiP�L� i 1�5 Phone# <br /> Consultant/Sub Contractor(tltmbrl2l En VtrMlMMigddress V70FIZ.1r rAS S-f. City JOnOrna:Lic# Phone# (.'10'1�935 '9'{s60 <br /> GIS Coordinates:X <br /> y.,Township Range Section <br /> WORK TO BE PERFORMED <br /> NEW WELL/BORING(CPT GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> 4CSOILBORING# Sg'5 t SEt _6 DOVER-BORE <br /> # PRESSURE GROUT <br /> 0 WELL <br /> 'Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE Z i� MULTIPLE CASINGS?0 YES *0 WELL CASING DIA' I� A <br /> A <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL p PVC 0 OTHER: <br /> 0 VAPOR p MUD ROTARY DEPTH OF GROUT SEAL—19O b TREMIE TYPE TO BE USED: GAUGERS NOSE <br /> 0 AIR SPARGE O PUSH POINT GROUT SEAL PUMPED: O Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> `SOIL BORING 0 HAND AUGER CONDUCTOR INGCASDEPTH <br /> NG PROPo10 0 NO (a BOLYESTED specificationsIC BOX <br /> here):_0 STOVE PIPE <br /> 0 OTHER: 0 OTHER <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 Ceunly Ordinances,State Laws,and Rules <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,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, 1 shall employ persons subject to <br /> WORKERS'COMPENSATION Laws of California.' <br /> CAL T E UN CTTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed /(�rV Title/Company A, coi <br /> !K O 0 <br /> Print Name INC Date <br /> .!,VARI IN,IUW ffl M <br /> DEPARTMENT USE ONLY <br /> Date Issuetl s DG Area <br /> Application Accepted By Data Z <br /> ni-tti� Dale Z Final Inspection By <br /> Grout Inspection By___o <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> I <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK* REC'D BY GATE PERMIT I SERVICE REQUEST# INVOICE <br /> 3So1 g .00 103s l s�? °� oo2loL8� <br /> 1/18/2000 <br />