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WELL PERMIT APPLICATION FORM UNIT IV SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) 304 E. Weber, Third Floor, Stockton, CA., 95202 (209) 468-3449 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ipl+Cat,Cn is hereby mads to San Joaquin County for a permit to Construct anWor install the work descnbed This appiicatron is made in compliance with ,n J"Quin Coun�tyy�D/ew7e:�ap7ment T,iwtW Chapte1r 9.1115 3 and the Standards of San Joaquin County PvbGc Health Services,Environmental Health Orvrslon ELL Location L 7 L�v•So ,(C✓ ST_ Cross Street f. �1 V h,S f- k Zi Assessor's �... //'fc�r G, p� n p S2��Parce!elrp-ZS"D-pS tOPERTY Owner/� C/IFr'Ct (2&-+C1 Address2-PO-1 at71,01 54-r?QO CityS.�rt F .kE"ip7y/ Phone /s S�y-68yZ �� s�// St CcntractQt W,7 t&2 Z rh C1f Address 2.Z f,f=90�2'l� tyG .v lip_. 5� . �cxSS ncne - z7 j v msultartt,'Sub ContraCor j�,w-� Caa.r.-�t�,74wdress P�fox ` 35`3 City 7` ier.l,c71[tG5'/9Pnanet t�y2B-DSB�t Ha 75r S Cco cinaies:X`____• Y� -'Tgwnsh +_! F a e___ _ _ _.�tCttan ORK TO BE PERFORMEl7 &EW WELL/BORING,,CPT- GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-; Q DESTRUCTION(Choose type Oelow) Q SOIL BORING K Q OVER-BORE ethe(: WELL A _`y� Q PRESSURE GROUT ;MMENTS' 'PE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS MONITORINGOLLOW STEM DIA,OF BOREHOLE MULTIPLE CASINGS-7 n YES )(NO WELL CASING DIA Z l EXTPACTION AIR HAMMERODRIVEN CASING THICKNESS C1 TYPE OF rASING Q STEEL pVC Q O't+EP_ V.4.POR C MUIV P,OTARY DEPTH OF GRO J' SEAL TREMIE TYPE T G BE U ED Q AUGERS CHOSE APR SPARGE n PUSH POINT GROUT SEAL PUMPED: 0 Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') SOIL BORING Q RANO AUGER APPROX BORING DEPTH_ ynQ BOLTED TRAFFIC BOX or Q STOVE PIPE O'HER_ n OTHER CONDUCTOR CASING PROPOSED? A)D _(it YES,list sperm fcations here). DMMENTS' fV O/�T---�—g e Yor NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS :err;t�y comity that I have prepared this application and that the worst will be done in accordance YfO, San Joaquin County Ordinances.State Laws,and R:;:es id Regulabons of the San Joaqurn County Horneovrner or licensed agent's signature certifies the following. "I Certify that In the performance o/the'work r wn/ch this permit Is Issued,i shall not employ persons sukect to WORKERS'COMPENSA 770N Laws of California." Contractor's hiring or sub- ,ntract,ng signature certifies the 1070wing. 'I Ceftrfy that in the perfomancc of the work fpr which this permit is Issued, I she empioy persons subject to '000KEPS'COMPENSATION Lows of Calrlomile.- THHE APPLICANT MUST CALL 48 WORKING NRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. fined s ' (/ �,r � %AQ-4.- Titk fi It L _ _1CDote n /l L 0�7 t SEE VITE MAP IN UNIT 1V WORK PLAN DATED' DEPARTMENT USE ONLY �� oplication Accepted Byl,/l�4dn�rltiyl 1 Date Issued / �_ Area rout Inspection By I.-,N rr DateCI / Final lnsptcton gym-- G Oate estruce4n Inspection By Date DMMENTS r CONDITIONS' ACCOUNTING ONLY. f AIDS FACI PE CODES FEE INFO AMOUNT REMITTED CHECK i RECD BY DATE PERMIT I SERVICE REQUEST t INVOICE 350 C)C) ys9 OCO,�" C-57 LICENSED CONTRACTOR MUST SIGN LICENSE&WORRFRS' COMPENSATION DECLARATION MIT IV- 6/23/99/sigi,bkpQ/MI FIL E COPY