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p <br /> 2- 10-2000 11 : 24AM FROM P . 1 <br /> i <br /> 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 /> NONREFUNDABLE 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, <br /> Chapter 9.1115-3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. ' <br /> pp p Il,t+�'1 YJ`-IF Assessor's <br /> WELLLocation CI AF� nt 'A or ki Qross Street 1 d City ZiP Parcel# <br /> rr In F•vn c - ISLE S • r" <br /> PROPERTY Owner4 Address Q Cfity/; Zip Phone# <br /> C-57Contractor I ,�--(( �I Adl!dress 1% Vr YCK ZZ� 1 City [>% j W Zip ` L74 ic# 67 I7 phone# qlG '3�y 'y `t'GO <br /> Cont / Sub Contractor) lrt04r� Address � rc�s + iacityllOn Lic# Phone# . "3 -15, 14 <br /> GIS Coordinates: X , Y.. Township Range Section <br /> WORK TO BE PERFORMED <br /> 7p NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH , HAND-AUGER, OTHER*) D DESTRUCTION (Choose type below) <br /> / � D SOIL BORING # D OVER-BORE <br /> D WELL # 2 U PRESSURE GROUT <br /> "Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS • , <br /> HOLLOW STEM DIA, OF BOREHOLE Q „ _ MULTIPLE CASINGS? D YES U NO WELL CASING DIA: <br /> MONITORING <br /> A Z_ <br /> D EXTRACTION D AIR HAMMER/DRIVEN CASING THICKNESS S[� `i0 TYPE OF CASING: II STEEL PVC O OTHER: <br /> U VAPOR D MUD ROTARY DEPTH OF GROUT SEAL 'Zr "C� TREMIE TYPE TO BE USED: D AUGERS UHOSE <br /> U AIR SPARGE D PUSH POINT GROUT SEAL PUMPED: Il Yes ONO (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> D SOIL BORING D HAND AUGER APPROX. BORING DEPTH ZS r - )(BOLTED TRAFFIC BOX or D STOVE PIPE <br /> U OTHER:.a OTHER CONDUCTOR CASING PROPOSED? 0 ( if YES, list specifications here): <br /> IF <br /> COMMENTS " SII Sr < nalS tr) ` arc ra k <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br />!r 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 Was <br /> and Regulations Of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: "I oertify 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 California." 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, I shall employ persons subjeet to <br /> WORKERS' COMPENSATION Laws of Califomia, " <br /> CALL THE 'UNITIY INSPECTOR 48 WORKING HRS IN ADVPIN.CE.FOR_ ALL REQUIRED+(INSPECTjIO—N& <br /> Signed /rXcu ,_y_ rale/CompanyC� Str-'��s � — l.l.Qr "� <br /> Print Name \ C' cll �rrr ✓� �'' � Date_ — / 0 ~ IFIF <br /> SEE'�S1TE: MAP• = ►IN":'flf # k�? 11f)RPE�Piit �DATED ®� <br /> DEPARTMENT USE ONLY C� <br /> Application Accepted By © <br /> Date Issued Z <br /> Grout Inspection By 1 &A ,2oi� Date $ Final Inspection By <br /> Destruction Inspection By Date <br /> COMMENTS ] CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT / SERVICE REQUEST # INVOICE <br /> 301 s . dr, s� z I 3 ooa a <br />