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WELL PERMIT APPLICATION FORM UNIT IV <br /> ✓ 555P 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 appt�catlon is made m complra^ce with <br /> Joaquin County Development Tate Chapter 9-1115 3 and the Standards of San Joaquin County Public Health Services Environmental Health Division <br /> WELL Location eZoZ$� f'=r, / 4-1;9-Cross Street 9 c5laCity 4p,,y Zi Assessors <br /> ` p Parcel# <br /> PROPERTY Owner 1), `�O V1 �p y� Address <br /> f �`11'� ��,( ln� <br /> T `1 ' Address � ipZ�CIty H a Zip � tPhone# Sop <br /> C 57 Contractor V�Y�I Y'���1y1q JAddress ClyGS�tS jp145 1 ic#� 1�41hone# <br /> <i-oZ I5f <br /> Consultant!Sub Contractor b0 l G oCr C&'% F0 ki f l e? Do✓ado <br /> Address % Crty s rts_Lic# Phone#_aB5 <br /> GIS Coordinates X Y Townshiif <br /> p Range 9 Section <br /> WORK TO BE PERFORMED <br /> Z EW WELL I BORING(CPT GEOPROBE HYDROPUNCH HAND-AUGER OTHER-) O DESTRUCTION (choose t/pe below <br /> 0 SOIL BORING# ? <br /> d�NELL# -Z /Nt W �3 0 OVER-BORE <br /> 'Other O PRESSURE GROUT <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING y�HOLLOW STEM DIA OF BOREHOLE " MULTIPLE CASINGS-, YES r <br /> O [] r`!O \TELL CASING SIA oZ it <br /> �0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS 5aL► 40 TYPE OF CASING 0 STEEL, \7C <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED 0 OTHEF <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED Ales D AUGERS OSE <br /> p No (NOTE MAXIMUM FREE-FALL DEPTH 1S 301y <br /> 0 SOIL BORING O HAND AUGER APPROX BORING DEPTH_ OLTED TRAFFIC BOY or 0 STOVE PIPE <br /> 0 OTHER 0 OTHER CONDUCTOR CASING PROPOSED pecifica <br /> �,�{if YES list s bons ^ere) <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 Ord nances State Laws and Rules <br /> and Regulations of the San Joaquin County Homeowner or licensed agents signature certifies the following 'I certify that in the performance or the work <br /> for which this permit is issued l shall not employ persons subject to WORKERS'COMPENSATION Laws of California Cor+ractor s hinnc or sub <br /> contracting signature certifies the following "I certify that in the perfonnance of the work for which this permit is issued 1 shall employ persons subl-ct to <br /> WORKERS COMPENSATION Laws of Califomia <br /> THE APPLICANT MUST CALL 48 W RKING HRS 1N ADVANCE FOR ALL <br /> {{REQUIRED INSPECTIONS <br /> Signed x Title P_bta Date 1 t� <br /> SEE SITE P IN UNIT IV WORK PLAN DATED 1 o a -7 99 <br /> ApgllcatDEPARTMENT USE ONLY / !, <br /> ron Accepted By Date Issued �{�-"` _ <br /> Area <br /> Grout Inspection By <br /> Destruction Inspection By Date Final Inspection By ____D_ <br /> ate Date `—` <br /> COMMENTS 1 CONDITIONS L-S.-Y - ------ <br /> ACCOU <br /> NTING ONLY AID# FArft <br /> PFEE INFO AMOUNT REMITTED CHECK# LREC'D BY DATE PERMIT 1 SERVILE REQUEST# INVOICE <br /> p <br /> C-57 LICENSED CONTRACTOR '1UST SIGN LICENSE&WO„RKEKS,rC4NII'ENS—A TTON DECLARATION <br /> UNIT IV 6/23/99/sign bkpg/MI <br />