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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 per, 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 Health Division. <br /> Assessor's <br /> _ <br /> YVEi1- Location , i�17 S &u7C A� Cross Street .n.tCity ��t i Zip 9s2D() Parcel# e <br /> �f 9 ` Ll ,4 .� CIL Cit Ack�C, 1 Zip `/ SZ0* Phone# Z67-7S/ 7ZC3 <br /> PROPERTY Owner rIC ���� Address � Y <br /> C47 ContfactoAW( Lrlllrnl Address l" 0. D%x Z:Z11 City Ortl r1A 1Zi1p y�l Lic#j j - 617Phone#9Ik -3E'E % Mu <br /> onsult <br /> Ca / Sub Contractor l,� LC✓r^' -td-'� (2r' yP :+°tiAddmss 3 � 5 � , Iy�city & F1s?k Lic# Phcne# s/t <br /> GIS Coordinates: X., Y.. Township Range Section <br /> WORK TO BE PERFORMED I GI � Z S d C-S <br /> WNEW WELL / BORING ( CPT. GEOPROBE, HYDROPUNCH , HANG-AUGER, OTHER') )(DESTRUCTION (choose type below) <br /> U SOIL BORING x '$,OVER-BORE <br /> )9WELL # I 0PRESSURE GROUT <br /> 'Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS rr <br /> MONITORING HOLLOW STEM DIA, OF BOREHOLE IEI �r MULTIPLE CASINGS? U YES XNO WELL CASING DIA: <br /> Z <br /> xa EXTRACTION ❑ AIR HAMMER/DRIVEN CASING THICKNESS 4h SIG} TYPE OF CASING U STEEL X PVC o OTHER: <br /> Q VAPOR MUD ROTARY DEPTH OF GROUT SEAL 7 C TREMIE TYPE TO BE USED: [] AUGERS BHOSE <br /> U AIR SPARGE Q PUSH POINT GROUT SEAL PUMPED: ayes )( No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30 ') <br /> 0 SOIL BORING U HAND AUGER APPROX. BORING DEPTH 25 ' 3 L- -( BOLTED TRAFFIC BOX or p STOVE PIPE <br /> 0 OTHER :.0 OTHER CONDUCTOR CASING PROPOSED? f) O ( if YES, list specifications here): <br /> COM MENTS'- .� ZJ De's <br /> J-ns 11 ril fti, d '4f; Zs- R S 9Lril6 Z ( ' 6� <br /> NOTE_ OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> 1 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 Rule: <br /> and Regulations of the San Joaquin County, Homeowner or licensed agent's signature certifies the following: 01 oert,'fy that in the performance of the work <br /> for which this permit is issued, f shall not employ persons subject to WORKERS' COMPESSA77ON Laws of Califomia" Contractor's hiving or sub- <br /> contracting signature eerdfies the following: 7 certify that in the performance of the work for which this permit is issued, f shall employ persons Subject to <br /> WORKERS' COMPENSA PON Laws of California. " <br /> CA L THE UNIT'IV SPECTOR 48 WORKING HRS IN ADVAN.CE .FOR-ALL REQUIRED INSPECTIONS. <br /> Signed xTitlelCompany <br /> Print Name 3" t 1..j_ rri lvi cr ) Date f 6 G <br /> SEE7ZZITEJMiAP IIV #11+## 1�7 owC7RF� =PLAtA DATEF3 ! - <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Data Issued Z1/001, .A �--- <br /> Grout Inspection By Date D Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS / CONOMONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT I SERVICE =# INVOICE <br /> 3So ( , oc> 2l I 3 'hillOZZ <br />