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WELL PERMIT APPLICATION FORM UNIT IV <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SER <br />ENVIRONMENTAL HEALTH DIVISION (PHS-tA C • '" <br />g <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 JAN 0 7 2000 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE AL <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described.ThisPRIligiktff S-4t1e3ir;L:oSrryptince with <br />San Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmeniall=reIlth Division. <br />Assessor's <br />WELL Location ) 3 7 fy - i 0 vl S L _ Cross Street a k 51 - City C st ocR 61 Zip GI °') Parcel# /6-1 —CL -2G <br />PROPERTY Owner 110 F -Z itrale0 Address 0. vo 2.3 .“ City r1f "zci Zip q Phone# -3433 5 - <br />C-57 Contractor ildvg.t G,4-v vi',004 ACildress t-t CO 1\/ W 1c W0 - <br /> <br />y City 5 16 ci41,1Zip ci ;•0i - Lic# GO -;;/Phone# 146 7 - 00,6 <br />Consultant / Sub Contractor <br /> <br />Address City Lic# Phone# <br /> <br />GIS Coordinates: X <br /> <br /> , Township Range Section <br /> <br />WORK TO BE PERFORMED <br /> <br />O NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') <br />El-SOIL BORING # p <br />0 WELL # <br />0 DESTRUCTION (choose type below) <br />OVER-BORE <br />PRESSURE GROUT <br /> <br />*Other: <br />(COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE 2'. , MULTIPLE CASINGS? 0 YES E NO WELL CASING DIA: — \)%3 <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS — TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: (N <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL -1- - P - TREMIE TYPE TO BE USED: B AUGERS 01-10SE \ <br />0 AIR SPARGE APUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS <br />volt. BORING 0 HAND AUGER APPROX. BORING DEPTH 3L)/ 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />Zs.,.._ 13 OTHER: 0 OTHER CONDUCTOR CASING PROPOSED? V ( if YES, list specifications here) <br />COMMENTS: 1)v C <br /> f -c? <br />CZ) <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, I shall employ persons subject to <br />WORKERS' COMPENSATION Laws of California." <br />THE APPLICANT MUST CALL 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />SEE SITE MAP I UNIT IV WORK PLAN DATED:tciq' <br />Signed x 24.)-Y-LA Title If:?' (7 ,0(0 9 ,n5T Date ) 7 / OD <br />DEPARTMENT USE ONLY <br />f .“Date Issued A ( ZCICC) Area <br />c.-F /0;7' Date 7I (inal Inspection By <br />Date <br />Application Accepted By <br />Grout Inspection By / <br />Destruction Inspection B <br />COMMENTS / CONDITIONS: <br />Date <br />ACCOUNTING ONLY: AID# <br />FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE P UEST # INVOICE <br />2, O 1 ,''7.(? r, ' , ._ DVi' /V <br />C-57 LICENSED CONTRACTOR MUST SIGN LI NSE &WORKERS' C DECLARATION <br />UNIT IV - 6/23/99 /sign bkpg/MI