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WELL PERMIT APPLICATION FOmivl UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC 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/or install the work described. This application is made in corp iance-with: <br /> San Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental H9`5Ith Division. <br /> �I I � CrossStreetr / Assessor's <br /> WELLLocation � S I ink/YlKJ✓� (Tr-MMzr1Gh t' Cityyl Zip S'3� ' Parcel# <br /> PROPERTY Ownec%("icl1;T�5f-00- �s. Address �10Lrand Car City GLui GL, Zip qa7 Phone O,,) �9cj� X5 <br /> Cu�Un � <br /> C-57 Contractor Cx✓tLt'� 'c�N�i•//w��n�c' wlAddress C CQ ti M (, <br /> CM City/ Zip/ Lic#4012) Phon �24 V( <br /> ScY <br /> Consultant/Sub Contractor ! r( C Address �/Gli�/'✓ Lyl' rL�Y' City G OJ,Lic# U �7 Phone d' /�1�' <br /> � <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> NEW WELL/BORING(CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> I(SOIL BORING# 0 OVER-BORE <br /> 0 WELL# 0 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?0 YES ,R-NO WELL CASING DIA: /V/7 <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 EA4s/Q- TREMIE TYPE TO BE USED: O AUGERS OHOSE <br /> 0 AIR SPARGE 7OUSH POINT GROUT SEAL PUMPED: 0 Yes 0o (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 'SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH -2,5- 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER:_O 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,I shall not employ persons subject to WORKERS'COMPENSATION 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, /shall employ persons subject to <br /> WORKERS'COMPENSATION Laws of California." <br /> CALL THE UNIT IV INSPJECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed x Title/Company 5444 <br /> Print Name r ),C,n J `I l ),P?6") Date — �LLwC,µ A <br /> - <br /> SEE SITE MAP IN UNIT IV, WORK PLAN DATED: �u-� a Sc�F �`'ss�`'`�� <br /> DEPARTMENT USE ONLY <br /> Application Accepted By <br /> J Date Issued —� G Area O 7 <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By �� '�/' Date ]S <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 1/18/2000 <br />