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.ftw °_40. <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) FILE COP1 <br /> 304 E. Weber, Third Floor, Stockton, CA., 96202 <br /> (209) 468-3449 <br /> NDN-REFUNDABLE PERMIT EXPIRES Z YEAR FROM DATE ISSUED <br /> .ppiication 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 /> ;an 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 /> n a <br /> !� Cross Street tC '�S City �� (; Zip"I "y� Parcel# <br /> VELE Location t / <br /> ROPERtY Owner N1E' &_)Z` <br /> ,S dress ZI P% ����' City!� r Zip 752 Phhone# <br /> { ,Sf- }T Address 323S c� City /o Zip1 Y&ic t°hone# Z� &7Z7� <br /> . 12 Kilt <br /> :-57 Contractor //���� �, ��" ,!/ <br /> :onsuitant 1 Sub Contractor v�c.��',f12"+ddress l lam/ W1 City S�c# Phone#�7/� <br /> ;IS Coordinates:X Y Township Range Section <br /> YORK TO BE PERFORMED <br /> }<JEVd WELL f BORING(CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER-) 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE <br /> 0 WELL# D PRESSURE GROUT <br /> Other: <br /> ;QMMENTS: <br /> -YPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 1 <br /> ?MONITORING HOLLOW STEM DIA. OF BOREHOLE h k MULTIPLE CASINGS. i ES a NO WELL CASING DIA Zit <br /> ttXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS r y# TYPE OF CASING: 0 STEEL kPVC 0 OTHER: <br /> ]VAPOR © MUD ROTARY DEPTH OF GROUT SEAL 6ITREMIE TYPE TO BE USED: _-AUGERS �iOSE <br /> ](AIR SPARGE a PUSH POINT GROUT SEAL PUMPED: Ives 0 No (NOTE: MAXIMUM FREE-PALL DEPTH IS 30') <br /> ]`501 BORING ] HAND AUGER APPROX_ BORING DEPTI 0 ,� F, _ OLTED TRAFFIC BOX or 0 STOVE PIPE <br /> ] <br /> OTHER:_O OTHER CONDUCTOR CASING PROPOSED? X} (if YES. list specifications here). <br /> WOMMENTS: C57 11 J — <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> 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: 'Y certify that in the performance of the work <br /> for which this permit is issued, l shall not employ persons subject to WORKERS'COMPENSA TiGN 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, 1 shall employ persons subject to <br /> WORKERS'COMPENSATION Laws of Califomia." <br /> CALL TIME UNIT IV INSPECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed x ` —Title/Company� <br /> Print Name 1 / Dated <br /> SEE SITE MAP IN UNIT_IV WORK PLAN DATED: <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Issued - + Area Q <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS f CONDITIONS: <br /> it <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'A BY DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> i/1e/z000 <br />