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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 /> r Install the work described Thas application�s made m compliance with <br /> Application is hereby made to San Joaquin County for a permit to construct and/o <br /> San Joaquin County Development Title Chapter 9-1115 3 and the Standards of San Joaquin County Public Health Services Environmental Assessors ealth Division <br /> WELL Location 613 I ziGt L ' Cross Street <br /> Y City Z+p Parcel# OCI <br /> T`WZ <br /> ``0✓� `k tuAddress P• BOX 86 g City 1u kl%K Zip 915o Phone# <br /> PROPERTY Owner 1A-t t II n, <br /> � 1ZiP 1U � �c# J5 Phone# <br /> (9?5)313 <br /> C-57 Contractor AddressS Ca - Y -St�ca <br /> v - <br /> /1 �1 Z Sonoma, L,�# Phone# C�a-t�935 �}$SO <br /> Consultant l Sub ContractorCh tbrl& �y111'"N Address 70 PerKI't S` - City <br /> GIS Coordinates X <br /> Y Township Range Section <br /> WORK TO BE PERFORMED <br /> NEW WELL I BORING(CPT GEOPROBE HYDROPUNCH HAND-AUGER OTHER-) 0 DESTRUCTION(choose type below) <br /> SOIL BORING#LS15—S t- SB —lo d OVER-BORE <br /> a PRESSURE GROUT <br /> ❑WELL# <br /> -Other <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA BOHIRCKNE S 2 '' A. PLE PE OF CASING a YES X <br /> 0 STEEL <br /> Dp PVCLLp OTHER CASING A <br /> EXTRACTION Q AIR HAMMERlDR1VEN CASINGN - <br /> 0 VAPOR MUD ROTARY DEPTH OF GROUT SEAL 2p TREMIE TYPE TO BE USED 0 AUGERS *OSE <br /> AIR SPARGE PUSH POINT GROUT SEAL PUMPED 11 Yes 0 No (NOTE MAXIMUM FREE-PALL DEPTH IS 30') <br /> SOIL BORING HAND AUGER APPROX BORING DEPTH„ Q BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER 0 OTHER CONDUCTOR CASING PROPOSEDI �o (if YES list Specifications here) <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 County Ordinances,State Laws and Rules <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 work <br /> for which this permit is Issued,I shall not employ persons subject to WORKERS'COMPENSATION Laws of Calffomfa" Contractors hiring or sub <br /> contracting signature certifies the following "1 certify that in the performance of the work for which this permit is issued l shall employ persons subject to <br /> WORKERS COMPENSATION laws of Calilomia" <br /> CAL T E UN <br /> JTOR •48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS <br /> r ff r/t <br /> I ttlelCompany Q <br /> 7 Lr <br /> Signed z <br /> Print Name fir <br /> Date <br /> 2� % �, }: � <br /> P 41 <br /> 11" <br /> DEPARTMENT USE ONLY ## <br /> Date Issued �1 1 Cl Area <br /> Application Accepted By �n TT� Date <br /> Grout Inspection By nate Fula,Inspector B, <br /> Destruction Inspection By Date <br /> COMMENTS f CONDITIONS <br /> I <br /> . ACCOUNTING ONLY AID# <br /> Pi:CODES FEE INFO AMOUNT REMITTED CHECK# RI;C'D BY DATE PERMIT t SERVICE REQUEST# INVOICE <br /> 3;p� - oo [ 035 5 ! 00 002�dL5�a <br /> 1/18/2000 <br />