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WELL P RMIT APPLICATION FOf�vt u w <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ,; <br /> e <br /> ENVIRONMENTAL HEALTH DIVISION (ti PHS-EHD7i) f)0 <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 FNU `' 'I- <br /> 304 <br /> 0 <br /> (209) 468-3450 pFR/��,vll�jE/V �y9c <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 'V,/T�S��U <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 /> 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 /> � - z. <br /> WELL Location b I M- W i �rt 0', va-, Cross Street S�O l"i v1 4 City S' 0 C I� t)y) (( Zip y�0 y Parcel# ILL 7' U 7 <br /> PROPERTY Owner 1���2t^ r �h�ec�y v Address 11 5 Vu5�Q I gI vcl City 1`1 1�Gvaq U Zip Phone#530 620 �f$71 <br /> C57Contraaor c�v�dc"� °c Nyi�' +redress a0o 1✓- Lv (4tii �4y City Sr1�1✓ Zip55}05 Lic#6130}1l Phone# X67-1006 <br /> Consultant/Sub Contractor Address City Lim Phone# <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> 0 NEW WEE-LL/BORING (CPT, GEOPROBE,HYDROPUNCH, HAND-AUGER,OTHER-) a DESTRUCTION(choose type below) <br /> 3,SOIL BORING# a OVER-BORE a PRESSURE GROUT <br /> jJ WELL# <br /> -Other. <br /> ��MMENTS: <br /> TYPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br /> r� <br /> 0 MONITORING Q HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?a YES 0 NO WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS N/N TYPE OF CASING: Q STEEL 0 PVC 0 OTHER <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL T- P' TREMIE TYPE TO BE USED: 0 AUGERS 5HOSE <br /> 0 AIR SPARGE ,PUSH POINT GROUT SEAL PUMPED: 0 Yes /5 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGERAPPROX.BORING DE?TH 3O BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> 0 OTHER: CONDUCTOR CASING PROPOSED? (if YES.list specifications here): <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS? <br /> hereby cerity that I have prepares this application and that the worts will be done in acc.oreance with San Joaquin County Ordinances. State Laws,and Ruies <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,1 shall not employ persons subject to WORKMAN'S COMPENSAT ON Laws of Califomia." 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. I shall employ persons subject to <br /> WORKMAN'S COMPENSATION Laws of California.' <br /> // THE APPLICANT MUST CALL 48 HRS 1N ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Signed x AJ+� �'��li/t"I '� Title Yr�j *C) ()1001U 1 5 7 Date —�� —ql_ <br /> SEE SITE MAP IN UNIT IV WORK PLAN. DATED 3o 51� lqqq <br /> DEP TMENT USE ONLY //q -0ApolicationAccepted By 1Date Issuedor,4 ( ✓ Area �� <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> FAC# <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#JCASH I RECEIV D DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> ,=3-ro I 1 27, f <br /> UNIT IV-5/99/MI <br />