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JJ- <br /> M 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 Cescribed. This application is made in compliance with <br /> San Joaquin County Development Title. Chapter f� e1115A .3 and the Standards of San Joaquin Coun ,,Public <br /> - Health Services , Environmental <br /> Health Division. ' <br /> ��,�/ D.lS -kI„-, � W. YCross Street W City S '"`k fo'1 Zip Parcel# <br /> WELL Location ,fe tg b S . Frcln � /l-; <br /> Zip Phone# <br /> PROPERTY Owner L'-r'Ew <br /> Q Q}7,. Y �a Address City <br /> Ptj R v`B�i zaz r�zti <br /> C-57 Contractor r'95 I <br /> F - Itk Address Z2y I' Ic�AyfI City c ' W Zip Lic# Phone# <br /> onsulta ub Contractor <br /> C4 F W. 3✓ Cj -6LY AddressSZO � L✓ —CtYuJ <br /> . Township_ Range Stiction <br /> GIS Coordinates: X Y <br /> WORK 70 BE PERFORMED <br /> p DESTRUCTION (choose type below) <br /> .h! NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) 0 OVER-BORE <br /> SOIL BORING # / 0 PRESSURE GROUT <br /> 0 <br /> WELL # <br /> *Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> O PLE CASINGS? 0 YES 0 NO WELL CASING DIA._ <br /> O MONITORING HOLLOW STEM DIA. OF BOREHOLE Z MULTI <br /> TYPE OF CASING: 0 STEEL O PVC 0 OTHER: <br /> p EXTRACTION D AIR HAMMER DRIVEN CASING THICKNESS TREMIE TYPE TO BE USED 0 AUGERS OHOSE <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL <br /> 0 AIR SPARGE PUSH POINT GROUT SEAL PUMPED: 0 Yes �P No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30'; <br /> SOIL BORING 0 HAND AUGER APPROX. BORING DEPTHBOLTED TRAFFIC BOX or D STOVE PIPE <br /> p <br /> OTHER:.0 OTHER CONDUCTOR CASING PROPOSED? ( if YES , fist specifications here): <br /> COMMENTS , SOr -- <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 Rule- <br /> and Regulations, of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: 'I oeri,'fy that in the performance of the Work <br /> Contractor's hiring or sub- <br /> for which rhis permit is issusd. I shat! not employ persons subject to WORKERS' COMPENSATION Laws of callfomia." <br /> contracting signature certifies the following: 7 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 Celftbrn <br /> CALL THEUNITIV N . <br /> SPECTOR 48 WORKING HRS IN ADVANCE .FOpR-ALL REQUIRED INSPECTIONS. <br /> Signed x _ TRIelCOnI 1 <br /> Print Name .\ co TT -_DA.TEES <br /> LAN <br /> SEES 51fE P.„IIJ E1F�#f 1 fltllXRPC P - <br /> DEPARTMENT USE ONLY <br /> Application Accepted By %— <br /> Data Issued 2 DD Alfie <br /> Grout Inspection By ,.Ul�� _Date <br /> OG Final Inspection B Date <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 I SERVICE REQUEST # INVOICE <br /> 35o1 . 00 sca1 I 3zw ooa � ozC� <br />