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WELL PERMIT APPLICATfON FtRM UNIT IV <br /> SAN JOAQUIN COUNTY RUBLIC 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/Qr 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 /> WELL Location /Y 7 G s J+i.+c o 1 K $T Cross Street City 3747c- /o✓t Zip Parcel# <br /> _ /h o <br /> PROPERTY OWner�A lG✓s 1.,,'Tt SYnwdils 4!! e ddress]2 13104 Cit44.5Cv Zip Phone# <br /> C-57 Contractor 61-a ems Oo-i aft- -1 e Address C{S G Hew)e IG o.J Citye2EgotcL ZipfLCO Lic# Phone#rj7S 313 SIQOO <br /> Consultant/Sub Contractor.STi..7•,g, 44JWow ac,'? hdress 33-10 XOt. City! aaro.��Lic# -10�tLPhone#S-W 67Z'L4aO <br /> GIS Coordinates:X _,Y Township Range Section <br /> WORK TO BE PERFORMED <br /> I<NEW WELL/BORING CPT EOPROBE, YDROPUNC ,HAND-AUGER, OTHER*) 0 DESTRUCTION(choose type below) <br /> 0 SOIL BORING 0 OVER-BORE <br /> 0 WELL# D PRESSURE GROUT <br /> *Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?O YES 0 NO WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS OHOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING D HAND AUGER APPROX. BORING DEPTH I A O -C-J 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> OTHER: C 0 OTHER CONDUCTOR CASING PROPOSED? (if YES, list specifications here): <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 Ordinances, State Laws, and Rules <br /> and Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: "I certify that in the performance of the work <br /> for which this permit is issued,/shall not employ persons subject to WORKERS'COMPENSATION Laws of California." Contractor's hiring or sub- <br /> contractingsignat rtifies the : `l certify that in the performance of the work for which this permit is issued, I shall employ persons subject to <br /> WORKERS'C PE SATO aw f alifomia." <br /> PP A T MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed x Title ✓c7 Cc. I' 4✓!Q 0— Date ­5- 9l/00 <br /> SE SIT AP IN UNIT IV WORK PLAN DATED ) L , Vor o <br /> r . , (\� DEPARTMENT USE ONLY <br /> Application Accepted By � ,f��1` \�C}`�� Date Issued�6r atu Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> I <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> C-57 LICENSED CONTRACTOR MUST S GN LICENSE &WORKERS' COMPENSATION DECLARATION <br /> UNIT IV-6/23/99/sign bkpg/MI <br />