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WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD ORIGINAL <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 0-- <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 San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> Assessor's <br /> WELL Location 221 I , (Ue�*3 kmt Cross Street 0 kljX-c�,NCity ZipgE?Qg__Parcel# (17,3(O-Z l <br /> PROPERTY Owner(2001. r-1S_PQ TJ)i2TPtic�ddress 221( LOI LsoA J Wmity Zip` `Phone# <br /> C-57 Contractor dtd-'ress CityZip Lic# Phone# <br /> Consultant/Sub Contractor�DO� iLl. 1�A�Q� Address MS f24Dp=Wity(.,D 1 Lic#1c/7$-2Phone#' <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER" DESTRUCTION choose <br /> � ( type below) � <br /> 0 SOIL BORING# '�7 0 OVER-BORE <br /> 0 WELL# 0 PRESSURE GROUT <br /> 'Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> V,KrONITORING OLLOW STEM DIA.OF BOREHOLE_ 3 MULTIPLE CASINGS?H YES UU:�' WELL CASING DIA: Z rf <br /> H EXTRACTION H AIR HAMMER/DRIVEN CASING THICKNESS SC//40 TYPE OF CASING: H STEEL �C 0 OTHER: <br /> 0 VAPOR H MUD ROTARY DEPTH OF GROUT SEAL ZL'r— ' TREMIE TYPE TO BE USED: 0 AUGERS OSE <br /> H AIR SPARGE H PUSH POINT GROUT SEAL PUMPED: ffYes H No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> H SOIL BORING 0 HAND AUGER APPROX.BORING DEPTH Sn` —1/DLTED TRAFFIC BOX or 0 STOVE PIPE <br /> H OTHER:_H OTHER CONDUCTOR CASING PROPOSED? ) (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: '7 certify that in the performance of the work <br /> for which this permit is issued,/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,I shall employ persons subject to <br /> WORKERS'COMPENSATION Laws of California." <br /> * LLT IV IN ECTOR 48 WORKING HRS IN ADVANCE FOR ALL <br /> REQUIRED INSPECTIONS <br /> Signed x Title/Company f00 r G LIV J <br /> Print Name 5—F—Ot �I �� E_ Date RECEIVED <br /> SITE FILE ADD S ORK PLAN DATE: �1 Ate_ I2,Z��av Ra If 61 Zoon SEP <br /> DEPARTMENT USE ONLY d &.Uu— <br /> Application Accepted By Date Issued 0 Fp;; PUB0IC �r ES <br /> Grout Inspection By Date Final Inspection By NA <br /> Destruction Inspection By Date �® <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 1350/ 57 exp._WC/waiver C-57 Letter of Authorization to sign permit Encroachment doc(s). 5/17/00 <br />