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zttj WELL PERMIT APPLICATION FORM UNIT IV <br />✓WP <br />5P SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) ORIGINAL <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 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 />r� <br />WELL Location aZ� H� �a�� rtle o,,4 <br />cI y / / Assessor's <br />c ;t Cross Street G 7 City �GK �Dvl Zip Parcel# <br />PROPERTY Owner j� loo. O m <br />✓``•,'� <br />Address Q / � •54%5 l4� <br />P. �JD?< <OZb city ifGctVIGbRS Zip%-7564hone# 500 <br />1 <br />C-57 Contractor V'� W Y'% kt%v% Address <br />C) . boy, J� ( Cit t0 V t��i `+57 is#-1W504P O� <br />�• y� p � hone# 3 �� oZ,ZS15 <br />t- <br />50 0 GaLcIev% Foc> -kill Et Do✓gdo CEG Ccl IL) <br />Consultant/ Sub Contractor ielZow) c,*JU. <br />Address P"VLA,41Q t. 5u,fie.7City ill Lic#i§'/9t3SPhone# C/3it <br />GIS Coordinates: X , Y <br />,Township Range Section r <br />02/ !o <br />WORK TO BE PERFORMED <br />}� <br />lJ <br />s <br />ANEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) 0 DESTRUCTION (choose type below) <br />0 SOIL BORING # <br />0 OVER -BORE l <br />t�/VELL # M w - r <br />- M _L - /t1 "2', 0 PRESSURE GROUT <br />"Other: <br />� <br />\ <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS <br />�,Lj MONITORING 4frHOLLOW STEM <br />DIA. OF BOREHOLE MULTIPLE CASINGS? 0 YES 0 NO WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN <br />CASING THICKNESS Scan q -v TYPE OF CASING: 0 STEEL (a'�VC 0 OTHER: 0101 <br />0 VAPOR 0 MUD ROTARY <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS C70SE �I <br />0 AIR SPARGE 0 PUSH POINT <br />GROUT SEAL PUMPED: %fes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30'�� <br />0 SOIL BORING 0 HAND AUGER <br />APPROX. BORING DEPTH 5S`�-' �OLTED TRAFFIC BOX or 0 STOVE PIPE <br />0 OTHER:_0 OTHER <br />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: "1 certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to <br />WORKERS' COMPENSATION Laws of California." <br />THE APPLICANT MUST CALL 48 W RKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />Signed x Title Ke4lb�f-V4 GeOtOgh4Date 11 d <br />SEE SITE PIN UNIT IV WORK PLAN DATED: to 7 (`'t 1 <br />DEPARTMENT USE ONLY <br />Application Accepted By Date Issued / /—/Y� _` / AreaM2�q <br />Grout Inspection By Date Final Inspection By _pgte� <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: QGe/l p`,x W �Zee.,cl / W /$ <br />ACCOUNTING ONLY: AID# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PERMIT / SERVICE REQUEST # <br />INVOICE <br />r` <br />02/ !o <br />C-57 LICENSED CONTRACTOR MUST SIGN LICENSE &WORKERS' COMPENSATION DECLARATION <br />UNIT IV - 6/23/99 /sign bkpg/MI <br />