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" • • <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION ("PHS52HD") <br /> 304 E. Weber, Third Floor, Stockton, CA., 90 <br /> (209) 468-3450 FILE COP Y <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/or Install the work described. This application Is made In compliance with <br /> -- <br /> San Joaquin County Development Title,Chapter <br /> -- <br /> &7115.3 and the Standards of Sen Joaquin County Public Health Services, EnvironmentalHeal Division. <br /> oa <br /> WELL Locatlonl'1,00W Berl 1am n1H_ol t�Dr. Cross StreelG. . ,X60 r`Ti—Dlty�°ck-I-o n ZIp9�`�—�-Par�eta <br /> PROPERTY Owner � I lICL)In C dYI f- Address,,37i 44 L;nCo(n <br /> See LtL Address 23(osWi rrl I citySfoctfoN Zip S.L-SLlc#S/Zz6gPhon e#(2°9) fO Z <br /> G57 CohtredorP - <br /> Consultant/Sub ContradorIFRLC'Uiii Qfr:Ck� Addressl`ICO��U(eIIPhone# <br /> S'�-f� �City e-" Vrl�-ic# NFE <br /> GIS Coordinates:X <br /> y riA ,Township NA Range NA Section NA" <br /> WORK TO BE PERFORMED <br /> DESTRUCTION(choose type below) <br /> NEW WELL I BORING (CRT, GEOPROBE, HYDROPUNCH, HAND-AVGER,OTHER') 0 OVERBORE <br /> SOIL BORING# Q- z P5 2- �8 r 0 PRESSURE GROUT <br /> WELL# F-T r Y7- /�_ PT- t r- `%o <br /> 'Other. <br /> COMMENTS: <br /> TYPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS rr <br /> Gt " MULTIPLE CASINGS?yy YES 0 NO WELL CASING DIA: 2 <br /> MONITORING HOLLOW STEM Dt4 OF BOREHOLE__st. h <br /> EXTRACTION 0 AIR IHAMMER(DRIVEN CASING THICKNESS 3CO 5°O TYPE OF CASING: 0 STEEL PVC 0 OTHER: <br /> ]VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 0-ZSr r TREMIE TYPE TO BE USED: D AUGERS NOSE <br /> ] Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 3t)') <br /> AIR SPARGE p PUSH POINT GROUT SEAL PUMPED: _ <br /> VE <br /> ]SOIL.BORING Q HAND AUGER COTRAFFIC BOX <br /> NDUCTOR CASING PROPOSED? Yl OO l n YES,fisBOLTEstt specifications here): 0 PIPESTO <br /> 7 OTHER: <br /> �MMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITSI <br /> hereby certity that I have prepared Map and that the work will be done In accordance with San Joaquin County Onlinances,State Laws,and Rules <br /> and Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following:"1 certify that In lira performance o/the worn <br /> b <br /> it Is issued,I shall not employ persons subject to WORKMAN'S COMPENSATION Laws of California." Contractor's hiring or sub- <br /> 'or rrwhiwhich chg thfs permsignature certifies the fallowing:11 certify that n the performance of the wort*for which this permit Is Issued,I shall employ persons subject to <br /> rYORK11i COMPENSATION/Laws of California.' <br /> Signed 0 � <br /> SEE SITE MAP N UNIT IV WORK PLAN. DATED <br /> DEPARTMENT USE ONLY <br /> Date Issued z Area, <br /> Vocation Accepted By Final Inspection 8 - Date <br /> 3rout Inspection By Date <br /> .Final <br /> Inspection By Date <br /> OMMENTS I CONDITIONS: <br /> FAC# <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER, INVOICE <br /> 2q t) IP9O X36 z D 35�5� <br /> )NTT TV-5199/MT <br />