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WELL PERMIT APPLICATION FORM UNIT IV <br /> S3�I1t13S;1114�Jd SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> Hl�bdN1N31n1h'10&1AhP ENVIRONMENTAL HEALTH DIVISION ("PHS-EHD") <br /> 1001 j 0 am E. Weber, Third Floor, Stockton, CA., 95202 <br /> l (209) 468-3450 <br /> M,/o I l -�' 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 s Health Division. <br /> �o.GTzb YQ city S-`DCkfiO+ p Parcettt00.�"7I� -02./03 <br /> WELL Location -70'LPor�ex' �VQ Cross Street,_ LI, <br /> PROPERTY Owner�%Vao / LAddress Cdy <br /> Zip tPhone:_ <br /> sO191 - iy-wrS1CPhoner <br /> 9ys)n313(�2$L$�pDV <br /> C-57 Contractor GfeA [) \J\ n _Address � 9 <br /> /' b!\D.C't�V1 yy � Iy Phene#���-1�7 - T OSQ <br /> Consultant/Sub Contractorti4M t'OtSY�ttiS9lAotlress27� I�t"I[1hS S�• City�'MQ Licit <br /> Range Secuon <br /> GIS Coordinates:X <br /> Y Township <br /> WORK TO BE PERFORMED <br /> 0 DESTRUCTION(choose type below) <br /> g,lEw WELL/BORING (CPT,GEOPROBE. HYDROPUNCH.HAND-AUGER.OTHER-) a OVER-BORE <br /> 0 SOIL BORING it 0 PRESSURE GROUT <br /> V<VELL 9 MW IL <br /> 'Other: <br /> CCMMENTS: <br /> TYPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS _� rr <br /> ,.,G r, MULTIPLE CASINGS?0 YES RNO WELL CASING DIA:? <br /> fJMONITORING OOLLOW STEM DIA.OF BOREHOLE <br /> 0 EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS St,N4 TYPE F:CASING: <br /> E O STEEL 8E USoV 9�QUGERSR OHOSE <br /> !�VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 6O ETYP <br /> Q AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: g`N 0 No (NOTE: MAXIMUM TRAFFIC of D EPTH IS STOVE PIPE <br /> D') <br /> 0 SOIL BORING O HAND AUGER APPROX. BORING DEPTH S O OILTEO <br /> OTHER: CONDUCTOR CASING PROPOSED? WO (if YES, list specifications here): <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS! <br /> I nereby certify that I have prepared this application and mat me work will be done in accordance wdtr 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: "1 certify that in the performance of the work <br /> for which this permit is issued,f shall not amploy persons subject to WORKMAN'S COMPENSATION Laws of California." Contractor's hiring to 5ub- <br /> contracting signature certifies the following: -I certify that in the performance of the work for which this permit is issued. i shell employ persons subject o <br /> WORKMAN'S COMPENSATION Laws of Califomia.' <br /> AP CANT MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed x <br /> /�-1 ii/JYl/t �ls_•w Tale /OfGl/�41�C 'e ?i I? O <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATED <br /> DEPARTMENT USE ONLY <br /> Date Issued Area <br /> Application Accepted By Date <br /> Grout Inspection By <br /> Date Final Inspection By <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> FAC» <br /> ACCOUNTING ONLY: AlOtt <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKNJCASH RECEIVED BY GATE PERMITISERVICE REQUEST NUMBER INVOICE <br /> oo aSyz <br />