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2-10-2000 11:24AM FROM
<br />WELL PERMIT APPLICATION FORM
<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 />UNIT IV
<br />P_ 1
<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 />P r ASSeSSOr'S
<br />WELL Location 0�7 J 'Si�G C�Vt Cross Street �^/ City Zip �`�Z Parcel#
<br />11� 1
<br />PROPERTY Owner lJl (l)4T�'� Address C1 7j4 1"R, .1 6ic7 L1ccl(yity J' k lL`1 Zip y SZC Phone#
<br />C-57 Contractor s- IZv', 5af'�ini Address22j j,�K�bhfY At -t- City , I1K� V "'�" Lic#_�WCY_.Phone# 51U "Z'1 Z71
<br />Z
<br />Consultant)/Sub Contractor c:'w"- ;Z.,_AddressS { `}� IQ'1_—L�
<br />City '�`b'x� ' Phone# -SX; 9.�
<br />GIS Coordinates: X Y Township Range Section
<br />WORK TO BE PERFORMED
<br />NEW WELL I BODING (CPT. GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER") p DESTRUCTION (Choose type below)
<br />SOIL BORING # �- 0 OVER -BORE
<br />0 WELL # p PRESSURE GROUT
<br />*Other:
<br />COMMENTS:
<br />TYPE OF WELL
<br />INSTALLATION TYPE
<br />p MONITORING
<br />0 HOLLOW STEM
<br />0 EXTRACTION
<br />0 AIR HAMMER/DRIVEN
<br />0 VAPOR 0 MUD ROTARY
<br />0 AIR SPARGE ')(PUSH POINT
<br />SOIL BORING 0 HAND AUGER
<br />p
<br />OTHER:_0 OTHER
<br />CONSTRUCTION SPECIFICATIONS
<br />DIA, OF BOREHOLE Z �_ MULTIPLE CASINGS? 0 YES 0 NO WELL CASING DIA.
<br />CASING THICKNESS TYPE OF CASING: U STEEL 0 PVC 0 OTHER:
<br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED' 0 AUGERS GHOSE
<br />GROUT SEAL PUMPED' 0 Yes X No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30')
<br />APPROX, BORING DEPTH; r _ 0 BOLTED TRAFIfIC BOX or 0 STOVE PIPE
<br />CONDUCTOR CASING PROPOSED? (if YES, list specifications here)'
<br />COMMENTS- jem/1c rw r_l r i✓Ki +9 CILLQ St ASr;,I'll IOU
<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 certiPl that in the performance of the work for which this permit is issued, i Shall employ persons subject to
<br />WORKERS' COMPENSATION Laws of California "
<br />CALL THE UNIT'IV IN'PECTOR 48 WORKING HRS IN ADVANCE FORALLREQUIRED INSPECTIONS.
<br />Signed xis" �' Title/Company
<br />Print Name �✓ `^tet �c� 1 Date L - I 0
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<br />DEPARTMENT USE ONLY
<br />z
<br />Application Accepted By Date Issued Area_
<br />Date
<br />Grout Inspection By_ /� �� Pate -3 15 OC) Final inspection By
<br />Destruction inspection By Date
<br />COMMENTS / CONDITIONS:
<br />n.,
<br />ACCOUNTING ONLY' AID#
<br />PE CODES
<br />FEE INFO
<br />AMOUNT REMITTED
<br />CHECK # REC'D BY
<br />DATE
<br />PERMIT 1 SERVICE REQUEST #
<br />INVOICI=
<br />3_�n�
<br />q
<br />21
<br />3 2-00
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