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i <br /> APPLICATION FORM UNIT IV <br /> WELL PERMIT , <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL. HEALTH DIVISION (PHS-EHD) J <br /> 304 E. Weber, Third Floor, Stockton, CA., 93202 <br /> (209) 468-3449 <br /> f NON-REFUNDAHi,E PIrRMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County far a permit to construct andlor install the work dEscribed. This application is made in compliance wits, <br /> San Joaquin County Development Title, Chapter 9-1115,3 and the Standards of San Joaquin County Public Health Serviceu� <br /> Environmental As essa 's Health Oi�is on. <br /> 5� CrassStreet6W{f rjCkity r Zip �Parcel>T0�?-O�b-� <br /> WELL Location 2 t �' <br /> SCity <br /> PROPERTY Owne -Address i Z,;,pp <br /> 5�Pt,oneT- <br /> l�Orvaabz150Lic#�_Phone;-YTh37318 <br /> C-57 — Pa <br /> 11 i' �3 #�Ci . Rr Lies FhonfFS.3 <br /> eD-�7 bo <br /> - OZ <br /> Consultant l Sub Cantractor��tp� Address (o <br /> Y Township Range Section <br /> GlS Coordinates:X , <br /> WORK TO BE PERFDRIV1Et7 <br /> j] DESTRUCTION (choose type befa%v) } <br /> )<NEW WELL/BORING(CPT.GEOPROBE, FiYDROPUNCH,HAND AUGER, OTHER') a OVIZR-BORE <br /> 0 SOIL BOR NG# � d 0 PRESSURE GROUT <br /> *Other: <br /> COMMENTS: <br /> TYPE 05 WELL INSTALLATION TYPE CONSTRUCTION SPECI ICATI MULTIPLE CASINGS?p YES p NO WELL CASING DIA-;r <br /> MONl7oP,ING HOLLOW STEM DIA- OF BOREHOLE—iv— <br /> AIR HAN3lV11=441DRIVEN CASING THICKNESS rt 1 TYPE OF CASING: 1]STEEL `�pVC 0 OTHEP: <br /> EXTRACTION I] TREMtE TYPE TO$E USED: AUGERS ` r105E <br /> Q VAPOR [] MVD ROTARY DEPTH OF GROUT SEAL <br /> P4R SPARGE p PUSH POINT GROUT SEAL PUMPED es 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') ' <br /> NAND AUGER APPROX. BOR.,SG DEP H OLTED TRAFFIC BOX ar Q STOVE PIPE <br /> SOIL BORING D t 7 if YES,lists specifications here): <br /> Q OTHER; � <br /> OTHER CONDUCTOR CASING PROPOSED? (" A <br /> COMMENTS: <br /> NOTE: OFFSITE BORING S;REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby certify that I,have prepared this application and that the work will be done in accorbanca with San Joaquin County Ordinances,State Laws, and Rule: <br /> and Regulations of the San,Joaquin County <br /> t employHomeowner <br /> mwnersorrs su6jecttonWORK1 R5'COMPENSATION Laws of Ct's s-Ignature certifies t',Ia following-, "I Jatiramia." Contractor's hiring or 07125 <br /> ub- t <br /> Sub- <br /> fop which this permit is issued,1 shall no P persons suhlect to <br /> contracting signature certifies The following; ',I certify that in the performance of the work for which this permit is issued, i shat!employ <br /> WORKERS'CoMPEp4S.47101V Laws of California." <br /> CALL THE I�l1T IV INSPECTOR +38 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Tltle/Company <br /> Signed x <br /> 7g �fJOd <br /> Print Name . �(QR <br /> E MAP""�N UNtT'"11f K PAN. �AT <br /> "SEE>�iT - <br /> DEPARTMENT USE ONLY 7 <br /> O Ir <br /> !l _ <br /> Date IssuedR > yU Area L_---� <br /> Application Accepted ByDate Final Inspection By Date) , <br /> Grout Inspection Ey <br /> Date <br /> Destruction Inspection By , <br /> COMMENTS f CONDITIONS: W. ` <br /> ,y <br /> I <br /> ACCOUNTING ONLY: AID# tt <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# RECD BY" GATE PERMIT l SER�V�IGREQUEST# INVOICE <br /> X561 v�s�zoaa <br /> PPbC'Q4.hr-M7 Qra _hT Mnn7 !T7 Ihr? _ <br />